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General NPI Number Information
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NPI Number | 1598165144
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Entity Type | Individual
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Provider Name | NICOLE JANINE CLARK MS STUDENTS WITH DIS
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Gender | Female
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 1787 VILLAGE LN N
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City | WANTAGH
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State | NY
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Zip | 11793-3228
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Country | US
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Telephone | 516-809-6866
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Fax |
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Provider Business Mailing Address
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Address Line | 1787 VILLAGE LN N
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City | WANTAGH
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State | NY
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Zip | 11793-3228
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1106362
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License Number State | NY
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