Provider Demographics
NPI:1265693048
Name:CLARK, ASHLEY DENISE (MS, LPP, BCBA-LBA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LPP, BCBA-LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0280
Mailing Address - Country:US
Mailing Address - Phone:606-349-7475
Mailing Address - Fax:606-349-7476
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-889-3610
Practice Address - Fax:606-886-1316
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYPPR00216455103T00000X
KY0070103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid