Active NPI
Kenneth W Clark, PH.D.
- Clinical Psychologist
- Madison, WI
National Provider Identifier
1942254560
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 670-057
- Practice address
- 6510 Grand Teton PLZ
Suite 406
Madison, WI 53719-1029 - Phone
- (608) 833-9290
- Fax
- (608) 833-9691
- NPI assigned
- May 19, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 670-057 | WI | Primary |
Addresses
Primary practice location
6510 Grand Teton PLZ
Suite 406
Madison, WI 53719-1029
Mailing address
6510 Grand Teton PLZ
Suite 406
Madison, WI 53719-1029
Phone (608) 833-9290
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 11676 | Other | WI | DEAN |
| 39012000 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 670-057 | WI | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| The Psychology Center S C | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Madison, WI
- NPI 1710942107
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147996800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1237507200000",
"number": "1942254560",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6510 GRAND TETON PLZ",
"address_2": "SUITE 406",
"city": "MADISON",
"state": "WI",
"postal_code": "537191029",
"telephone_number": "608-833-9290",
"fax_number": "608-833-9691"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6510 GRAND TETON PLZ",
"address_2": "SUITE 406",
"city": "MADISON",
"state": "WI",
"postal_code": "537191029",
"telephone_number": "608-833-9290",
"fax_number": "608-833-9691"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "KENNETH",
"middle_name": "W",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-19",
"last_updated": "2009-03-20",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "WI",
"license": "670-057",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DEAN",
"identifier": "11676",
"state": "WI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "39012000",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Madison, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 20, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.