Provider Demographics
NPI:1972151900
Name:CLARK, ELYSSA F (BCBA)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:F
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 1:2003 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4629
Mailing Address - Country:US
Mailing Address - Phone:303-968-4882
Mailing Address - Fax:
Practice Address - Street 1:270 E 8TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5708
Practice Address - Country:US
Practice Address - Phone:970-769-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-19-39650103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty