Provider Demographics
NPI:1811597537
Name:CLARK, EUGENIA (MA ED, BCBA)
Entity type:Individual
Prefix:
First Name:EUGENIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CIVIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4171
Mailing Address - Country:US
Mailing Address - Phone:628-877-0040
Mailing Address - Fax:628-240-3997
Practice Address - Street 1:4000 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4171
Practice Address - Country:US
Practice Address - Phone:628-877-0040
Practice Address - Fax:628-240-3997
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-73104103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst