Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TB0200X | Cognitive & Behavioral Psychologist | 003240 | CT |
Y | 103G00000X | Clinical Psychologist | 003240 | CT |
Y | 103TC0700X | Clinical Psychologist | 003240 | CT |
N | 103TH0004X | Health Psychologist | 003240 | CT |
NPI | 1073019527 |
---|---|
Provider Name | Elizabeth Anne Clark |
First Address | New Haven, CT 06515-1607 |
Second Address | West Haven, CT 06516-2770 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2018 |
Last Update Date | 03/04/2018 |