Healthcare Provider Details

I. General information

NPI: 1215688205
Provider Name (Legal Business Name): HEATHER CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 GRAND CENTRAL BLVD STE 101
POOLER GA
31322-4146
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 912-244-3305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: