Provider Demographics
NPI:1881172195
Name:CLARK, NATHAN EDWARD (MED, BCBA)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:EDWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 LEE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6574
Mailing Address - Country:US
Mailing Address - Phone:877-486-4140
Mailing Address - Fax:847-486-4145
Practice Address - Street 1:4433 W TOUHY AVE STE 335
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1820
Practice Address - Country:US
Practice Address - Phone:765-635-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-20-43731103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1-20-43731OtherBEHAVIOR ANALYST CERTIFICATION BOARD