Provider Demographics
NPI:1376207415
Name:CLARK, KRISTINA RENA (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:RENA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 ACR 1200
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:TX
Mailing Address - Zip Code:75839
Mailing Address - Country:US
Mailing Address - Phone:903-905-3515
Mailing Address - Fax:
Practice Address - Street 1:226 ACR 1200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:TX
Practice Address - Zip Code:75839
Practice Address - Country:US
Practice Address - Phone:903-905-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4234103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst