Provider Demographics
NPI:1043283724
Name:CLARK, TERRELL A (PHD)
Entity type:Individual
Prefix:
First Name:TERRELL
Middle Name:A
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 1:34 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01740-1120
Mailing Address - Country:US
Mailing Address - Phone:978-779-6133
Mailing Address - Fax:
Practice Address - Street 1:9 HOPE AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2741
Practice Address - Country:US
Practice Address - Phone:781-216-2200
Practice Address - Fax:781-647-8914
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2856103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent