Provider Demographics
NPI:1952188831
Name:CLARK, BRANDI DAWN (RBT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 NW 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:KS
Mailing Address - Zip Code:67576-8690
Mailing Address - Country:US
Mailing Address - Phone:316-730-1222
Mailing Address - Fax:
Practice Address - Street 1:710 NW 30TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:KS
Practice Address - Zip Code:67576-8690
Practice Address - Country:US
Practice Address - Phone:316-730-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician