Provider Demographics
NPI:1316538689
Name:CLARK, KINSEY LEE
Entity Type:Individual
Prefix:
First Name:KINSEY
Middle Name:LEE
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 1:568 N KAINALU DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2129
Mailing Address - Country:US
Mailing Address - Phone:864-838-9020
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD STE D8
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3172
Practice Address - Country:US
Practice Address - Phone:808-486-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician