Provider Demographics
NPI:1134877962
Name:CLARK, THERESA MARIE (BT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BT
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-854-1116
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:932 N MITCHELL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1285
Practice Address - Country:US
Practice Address - Phone:231-272-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician