Provider Demographics
NPI:1497098446
Name:CLARK, KATHLEEN PAULINE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:PAULINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:PAULINE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA, LBA
Mailing Address - Street 1:31 LONE HOLW
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5500
Mailing Address - Country:US
Mailing Address - Phone:801-647-5254
Mailing Address - Fax:
Practice Address - Street 1:31 LONE HOLW
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-5500
Practice Address - Country:US
Practice Address - Phone:801-647-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist