Bruce E Clark, PH.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP7036 Issued in MN

Practice address

3800 Park Nicollet Blvd
St Louis Park, MN 55416-2527

Phone

(952) 993-3123

Fax

(952) 993-3286

NPI assigned

May 30, 2024

Last updated

Aug 9, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MN2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Mindful You Behavioral Health PLLC

  • Clinical Psychologist
  • Forest Lake, MN
  • NPI 1568254811
  Medicare reassignment NPD Authorized official
• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1780621904
  Medicare reassignment NPD
• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1063897593
  NPD
• Park Nicollet Clinic

  • Family Medicine Physician
  • Minneapolis, MN
  • NPI 1912315144
  NPD

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

{
    "created_epoch": "1717027200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1723161600000",
    "number": "1669212395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8170 33RD AVE S # MS 21110Q",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554254516"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3800 PARK NICOLLET BLVD",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554162527",
            "telephone_number": "952-993-3123",
            "fax_number": "952-993-3286"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3366 Oakdale Ave N Ste 315",
            "address_purpose": "LOCATION",
            "city": "Robbinsdale",
            "state": "MN",
            "postal_code": "554222967",
            "country_code": "US",
            "telephone_number": "763-581-5372",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CLARK",
        "first_name": "BRUCE",
        "middle_name": "E",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-05-30",
        "last_updated": "2024-08-09",
        "certification_date": "2024-08-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP7036",
            "primary": true
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MN",
            "license": "LP7036",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Bok Chung, MD
• Nyahon Chieng Chut, PA-C
• Karen Marie Cieminski, P.T.
• Kelly Ann Clancey
• Jeanine Ruth Clapsaddle, M.A., LAMFT
• Christine Clark, PSY.D., L.P.
• Michael Steven Clark, M.D.
• Kristi L Clarkowski, CRNA
• Leann Clarksean, RN, CNP
• Brittany Nicole Clausell, ED.D.

• Psychologist in St Louis Park, MN
• Providers in St Louis Park, MN by specialty
• Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.