Provider Demographics
NPI:1518793223
Name:CLARK, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
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 1:3320 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:TX
Mailing Address - Zip Code:76140-2526
Mailing Address - Country:US
Mailing Address - Phone:817-713-2098
Mailing Address - Fax:
Practice Address - Street 1:7277 HAWKINS VIEW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3921
Practice Address - Country:US
Practice Address - Phone:682-291-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician