Mary Ann Clark, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PY0004772 Issued in FL

Practice address

300 Riverside Dr E
Ste 2000
Bradenton, FL 34208-1023

Phone

(941) 746-8822

Fax

(941) 746-8844

NPI assigned

May 31, 2005

Reactivated

Mar 29, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1117497600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1192665600000",
    "number": "1174526578",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 RIVERSIDE DR E",
            "address_2": "STE 2000",
            "city": "BRADENTON",
            "state": "FL",
            "postal_code": "342081023",
            "telephone_number": "941-746-8822",
            "fax_number": "941-746-8844"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 RIVERSIDE DR E",
            "address_2": "STE 2000",
            "city": "BRADENTON",
            "state": "FL",
            "postal_code": "342081023",
            "telephone_number": "941-746-8822",
            "fax_number": "941-746-8844"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "MARY ANN",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-05-31",
        "last_updated": "2007-10-18",
        "deactivation_date": "2006-03-20",
        "reactivation_date": "2006-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "FL",
            "license": "PY0004772",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROVIDER NUMBER",
            "identifier": "59504",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Angela C Clark, SLP
• Dalia Clark, MA
• Debra Diane Clark
• Elaine Rutherford Clark, LCSW
• Jennifer Michele Clark, LCSW
• Melissa Kipp Clark, AU.D.
• Michelle Elise Clark, N.D.
• Tatiana Clark, A.R.N.P.
• Virginia H Clark, OTR, CHT
• Janelle Colleen Clarkin, P.T., D.P.T.

• Clinical Psychologist in Bradenton, FL
• Providers in Bradenton, FL by specialty
• Clinical Psychologist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.