=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942187182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZAVETA VALERIEVNA CLARK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2025
-----------------------------------------------------
Last Update Date | 08/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1409 KEMPSVILLE RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-8134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-578-8608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 HIGHGATE CT
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-8096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-504-7739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-332628
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------