Provider Demographics
NPI:1952709107
Name:CLARK, MADELINE JULIA (BCBA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:JULIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:JULIA
Other - Last Name:WALENTINY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:PO BOX 767938
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-7938
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:7800 SW BARBUR BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2823
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1-18-32425OtherBCBA