1497098446 NPI number — KATHLEEN PAULINE CLARK MA, BCBA, LBA

Table of content: KATHLEEN PAULINE CLARK MA, BCBA, LBA (NPI 1497098446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497098446 NPI number — KATHLEEN PAULINE CLARK MA, BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
KATHLEEN
Provider Middle Name:
PAULINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
PAULINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA, LBA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1497098446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 LONE HOLW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84092-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-647-5254
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 LONE HOLW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84092-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-647-5254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com