Provider Demographics
NPI:1891397725
Name:CLARK, MOLLI A (RBT)
Entity Type:Individual
Prefix:
First Name:MOLLI
Middle Name:A
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 1:627 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-2461
Mailing Address - Country:US
Mailing Address - Phone:256-849-0444
Mailing Address - Fax:
Practice Address - Street 1:200 SAND MOUNTAIN DR E STE A
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-2369
Practice Address - Country:US
Practice Address - Phone:256-849-0444
Practice Address - Fax:256-849-0445
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-20-8742-256444106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician