Provider Demographics
NPI:1790355790
Name:CLARK, DEJA
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:
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 1:1500 DOUGLAS ROAD, SUITE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:844-854-1116
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:6180 GROVEDALE CT # 200
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2552
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70337054Medicaid