Provider Demographics
NPI:1558722082
Name:CLARK, COURTNEY (BCBA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CLARK
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 1:230 E CONWAY RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-4002
Mailing Address - Country:US
Mailing Address - Phone:603-273-9270
Mailing Address - Fax:603-255-7446
Practice Address - Street 1:230 E CONWAY RD
Practice Address - Street 2:
Practice Address - City:CENTER CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03813-4002
Practice Address - Country:US
Practice Address - Phone:603-273-9270
Practice Address - Fax:603-255-7446
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1-16-23719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3137577Medicaid