Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 1810AP-PL | AR |
N | 103T00000X | Psychologist | 1810AP-PL | AR |
NPI | 1003284274 |
---|---|
Provider Name | Mr. Clark Robert Thompson |
First Address | Northfield, IL 60093-3006 |
Second Address | Fayetteville, AR 72703-1822 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2015 |
Last Update Date | 31/10/2018 |