Provider Demographics
NPI:1891150082
Name:CLARK, LAURA DANAE (BCBA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DANAE
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 1:459 PRESERVE CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4676
Mailing Address - Country:US
Mailing Address - Phone:406-579-5360
Mailing Address - Fax:920-857-3366
Practice Address - Street 1:3007 HARBOR LN N STE 1200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5103
Practice Address - Country:US
Practice Address - Phone:612-439-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI124-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst