Provider Demographics
NPI:1780823351
Name:CLARK, ANN M (BCBA)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
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 1:5550 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3357
Mailing Address - Country:US
Mailing Address - Phone:708-334-7492
Mailing Address - Fax:
Practice Address - Street 1:5550 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-3357
Practice Address - Country:US
Practice Address - Phone:708-334-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst