Provider Demographics
NPI:1073867354
Name:CLARK, CRISTEN CLARE (BACHELORS PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:CRISTEN
Middle Name:CLARE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BACHELORS PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17424
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-0424
Mailing Address - Country:US
Mailing Address - Phone:808-548-1735
Mailing Address - Fax:
Practice Address - Street 1:615 PIIKOI ST STE 105
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3139
Practice Address - Country:US
Practice Address - Phone:808-596-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst