Provider Demographics
NPI:1134696578
Name:CLARK WILKES, KRYSTEN (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTEN
Middle Name:
Last Name:CLARK WILKES
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 PEACE CHANCE DR
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3162
Mailing Address - Country:US
Mailing Address - Phone:702-266-6584
Mailing Address - Fax:
Practice Address - Street 1:652 PEACE CHANCE DR
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3162
Practice Address - Country:US
Practice Address - Phone:702-266-6584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst