Provider Demographics
NPI:1922757798
Name:CLARK, KATELIN
Entity Type:Individual
Prefix:
First Name:KATELIN
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 1:3131 SW 89TH ST APT 5205
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7932
Mailing Address - Country:US
Mailing Address - Phone:405-923-2055
Mailing Address - Fax:
Practice Address - Street 1:3131 SW 89TH ST APT 5205
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7932
Practice Address - Country:US
Practice Address - Phone:405-923-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician