Healthcare Provider Details

I. General information

NPI: 1669965927
Provider Name (Legal Business Name): ALEXISS CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N GRANVILLE AVE
MUNCIE IN
47303-2155
US

IV. Provider business mailing address

7405 WESTFIELD BLVD
INDIANAPOLIS IN
46240-3056
US

V. Phone/Fax

Practice location:
  • Phone: 765-748-5116
  • Fax:
Mailing address:
  • Phone: 765-748-5116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-21-12135
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: