Provider Demographics
NPI:1669623708
Name:CLARK, SANDRA KAY
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
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 1:16503 W MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6170
Mailing Address - Country:US
Mailing Address - Phone:623-882-1054
Mailing Address - Fax:
Practice Address - Street 1:16503 W MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6170
Practice Address - Country:US
Practice Address - Phone:623-882-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ650836103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst