Individual
DR. KENNETH W CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
6510 GRAND TETON PLZ, SUITE 406, MADISON, WI 53719-1029
(608) 833-9290
(608) 833-9691
Mailing address
6510 GRAND TETON PLZ, SUITE 406, MADISON, WI 53719-1029
(608) 833-9290
(608) 833-9691
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
670-057
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11676
DEAN
WI
05
—
39012000
—
WI
Enumeration date
05/19/2006
Last updated
03/20/2009
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