Healthcare Provider Details

I. General information

NPI: 1538838818
Provider Name (Legal Business Name): CAITLIN TONIA CLARK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 10/06/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S MAIN ST
BOUNTIFUL UT
84010-6265
US

IV. Provider business mailing address

541 LACEY WAY
NORTH SALT LAKE UT
84054-1530
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax: 801-935-4946
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number8710931-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-181046
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: