Provider Demographics
NPI:1255004529
Name:CLARK, SAMANTHA JO (BA, RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-3301
Practice Address - Country:US
Practice Address - Phone:540-588-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician