Healthcare Provider Details

I. General information

NPI: 1245845320
Provider Name (Legal Business Name): MAREN ALEXANDRA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAREN ALEXANDRA JOHNSON

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ATLAS AVE
MADISON WI
53714-3108
US

IV. Provider business mailing address

502 ATLAS AVE
MADISON WI
53714-3108
US

V. Phone/Fax

Practice location:
  • Phone: 833-646-3222
  • Fax:
Mailing address:
  • Phone: 833-646-3222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number528140
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: