Provider Demographics
NPI:1972061885
Name:CLACK, COURTNEY CAROLANN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CAROLANN
Last Name:CLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:CAROLANN
Other - Last Name:BORUNDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 SCENIC DR APT D
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4441
Mailing Address - Country:US
Mailing Address - Phone:575-415-2906
Mailing Address - Fax:
Practice Address - Street 1:301 SCENIC DR APT D
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4441
Practice Address - Country:US
Practice Address - Phone:575-415-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician