Provider Demographics
NPI:1639985609
Name:CLARK, KAYLA CIERRA ELAINE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:CIERRA ELAINE
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:PO BOX 360595
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-6595
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:718-865-5165
Practice Address - Street 1:12210 PLUM ORCHARD DR STE 21
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7911
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:718-865-5165
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRBT-24-397061106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician