Provider Demographics
NPI:1053558205
Name:CLARK, THOMAS EDWARD (LMFT, LMFT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMFT, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12202
Mailing Address - Country:US
Mailing Address - Phone:518-662-0621
Mailing Address - Fax:
Practice Address - Street 1:980 WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12202
Practice Address - Country:US
Practice Address - Phone:518-662-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56783390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56783OtherMFT INTERN NUMBER