Provider Demographics
NPI:1639714298
Name:CLARK, KRISTEY LEE
Entity Type:Individual
Prefix:MRS
First Name:KRISTEY
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:FAIRACRES
Mailing Address - State:NM
Mailing Address - Zip Code:88033-0515
Mailing Address - Country:US
Mailing Address - Phone:575-644-9889
Mailing Address - Fax:
Practice Address - Street 1:3 BUTTERFIELD TRAIL BLVD STE 140
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79906-4951
Practice Address - Country:US
Practice Address - Phone:800-991-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst