Provider Demographics
NPI:1760042444
Name:CLARK, TABITHA K
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:K
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 1:520 NE COLBERN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4711
Mailing Address - Country:US
Mailing Address - Phone:816-643-4959
Mailing Address - Fax:
Practice Address - Street 1:520 NE COLBERN RD STE 200
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4711
Practice Address - Country:US
Practice Address - Phone:816-643-4959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2023-08-04
Deactivation Date:2023-07-07
Deactivation Code:
Reactivation Date:2023-08-02
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MO2023027231103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician