Derrick J Clark, PHD

Primary specialty

PsychologistTaxonomy code 103T00000X

License

PSY13424 Issued in CA

Practice address

1663 Dominican Way
Ste 214
Santa Cruz, CA 95065-1527

Phone

(831) 475-3231

Fax

(831) 462-4936

NPI assigned

Sep 7, 2006

Sex

Male

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

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

{
    "created_epoch": "1157587200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1568566917",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1663 DOMINICAN WAY",
            "address_2": "STE 214",
            "city": "SANTA CRUZ",
            "state": "CA",
            "postal_code": "950651527",
            "telephone_number": "831-475-3231",
            "fax_number": "831-462-4936"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1663 DOMINICAN WAY",
            "address_2": "STE 214",
            "city": "SANTA CRUZ",
            "state": "CA",
            "postal_code": "950651527",
            "telephone_number": "831-475-3231",
            "fax_number": "831-462-4936"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "DERRICK",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "PHD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-07",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "CA",
            "license": "PSY13424",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PSY134241",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kevin Osugi Cisneros
• Stephanie None Cisneros
• Gianluca Ciulla, CMT
• Ellen Clack
• Adriana Del Pilar Clark, DDS
• Jennifer Clark, LMFT
• Kacy Clark
• Meg Kristine Clark
• Ron Wayne Clark
• Thomasina Clark

• Psychologist in Santa Cruz, CA
• Providers in Santa Cruz, CA by specialty
• Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 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.