Provider Demographics
NPI:1508255365
Name:CLARKE, ANGELIN (BCBA)
Entity Type:Individual
Prefix:
First Name:ANGELIN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 TELLSON PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-8673
Mailing Address - Country:US
Mailing Address - Phone:407-906-1477
Mailing Address - Fax:407-590-2018
Practice Address - Street 1:4837 TELLSON PL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-8673
Practice Address - Country:US
Practice Address - Phone:407-906-1477
Practice Address - Fax:407-902-0187
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-9630103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21584300Medicaid