Provider Demographics
NPI:1770459554
Name:CLARK, ALEXANDRIA MARIAN
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MARIAN
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 1:1570 DUBLIN BLVD APT 135
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3278
Mailing Address - Country:US
Mailing Address - Phone:720-425-0686
Mailing Address - Fax:
Practice Address - Street 1:1015 GARDEN OF THE GODS RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3489
Practice Address - Country:US
Practice Address - Phone:719-354-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst