Provider Demographics
NPI:1891275780
Name:CLARK, ELLEN C (RBT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 W 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-3404
Mailing Address - Country:US
Mailing Address - Phone:918-813-9623
Mailing Address - Fax:
Practice Address - Street 1:7725 W 87TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1905
Practice Address - Country:US
Practice Address - Phone:913-649-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSRBT-17-37106106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician