Healthcare Provider Details

I. General information

NPI: 1437824752
Provider Name (Legal Business Name): MISS KAELEIGH S CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 JAY ST STE 501
BROOKLYN NY
11201-4398
US

IV. Provider business mailing address

PO BOX 823
NEWBURGH NY
12551-0823
US

V. Phone/Fax

Practice location:
  • Phone: 347-304-9465
  • Fax: 631-850-6900
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017266
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: