Provider Demographics
NPI:1578981403
Name:CLARK, LEAH ELIZABETH (EDS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:EDS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 JONES ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2753
Mailing Address - Country:US
Mailing Address - Phone:712-259-1084
Mailing Address - Fax:
Practice Address - Street 1:5601 SUNNYBROOK DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4205
Practice Address - Country:US
Practice Address - Phone:712-746-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105829103K00000X
NE2018003232103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool