Provider Demographics
NPI:1275421349
Name:CLARK, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MOBERLY AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1447
Mailing Address - Country:US
Mailing Address - Phone:859-779-9982
Mailing Address - Fax:
Practice Address - Street 1:870 CORPORATE DR STE 104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-5417
Practice Address - Country:US
Practice Address - Phone:859-785-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-25-446943106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician