Provider Demographics
NPI:1053362533
Name:CLARK, SARAH L (PHD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W WILSON BRIDGE RD
Mailing Address - Street 2:STE 30
Mailing Address - City:WORTHINGTON, OH
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2288
Mailing Address - Country:US
Mailing Address - Phone:614-560-3995
Mailing Address - Fax:
Practice Address - Street 1:500 W WILSON BRIDGE RD
Practice Address - Street 2:STE 30
Practice Address - City:WORTHINGTON, OH
Practice Address - State:OH
Practice Address - Zip Code:43085-2288
Practice Address - Country:US
Practice Address - Phone:614-560-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5484103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375513Medicaid
OHS72252Medicare UPIN
OH2375513Medicaid