NPIMap

Individual provider Active NPI

Lisa Clark, PH.D.

  • Clinical Psychologist
  • Riverdale, GA
National Provider Identifier
1952378226
Registry record updated Feb 10, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PSY002509 Issued in GA
Practice address
225 Medical Way
Riverdale, GA 30274-2522
Phone
(678) 519-1038
Fax
(770) 756-9195
NPI assigned
Mar 4, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 10, 2011

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X PSY002509 GA Primary

Addresses

Primary practice location

225 Medical Way
Riverdale, GA 30274-2522

Mailing address

4557 Meadow Creek Path
Lithonia, GA 30038-7704
Phone (678) 519-1038

Other identifiers 7

IdentifierTypeStateIssuer
000910929HMedicaidGA
000910929KMedicaidGA
000910929LMedicaidGA
000910929IMedicaidGA
000910929GMedicaidGA
000910929EMedicaidGA
000910929FMedicaidGA

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

Practice roles

OrganizationSpecialtyStatusNew patients
Lisa Clark Enterprises, Inc Clinical PastSince Nov 9, 2005 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.

NPI Registry JSON

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

{
    "created_epoch": "1141430400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1297296000000",
    "number": "1952378226",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4557 MEADOW CREEK PATH",
            "city": "LITHONIA",
            "state": "GA",
            "postal_code": "300387704",
            "telephone_number": "678-519-1038",
            "fax_number": "770-756-9195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "225 MEDICAL WAY",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302742522",
            "telephone_number": "678-519-1038",
            "fax_number": "770-756-9195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "LISA",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-03-04",
        "last_updated": "2011-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "GA",
            "license": "PSY002509",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929H",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929K",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929L",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929I",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929G",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929E",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000910929F",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Riverdale, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2011; 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.