Provider Demographics
NPI:1942572698
Name:CLARK, CONNIE (PHD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-9076
Mailing Address - Country:US
Mailing Address - Phone:724-691-2460
Mailing Address - Fax:
Practice Address - Street 1:2230 BOYD RD
Practice Address - Street 2:
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15632-8997
Practice Address - Country:US
Practice Address - Phone:724-691-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACL74399101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral