MEDICARE: VERENA CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-25-455774	NM
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1629866173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERENA CLARK

Provider Business Mailing Address
First Line	:	5382 LA CUEVA ST SW
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-9179
Country	:	US
Telephone Number	:	505-403-7759
Fax Number	:

Provider Business Practice Location Address
First Line	:	5382 LA CUEVA ST SW
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-9179
Country	:	US
Telephone Number	:	505-403-7759
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2025
Last Update Date	:	08/20/2025

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Directions to “ VERENA CLARK ” Practice Location

Language	Start Address	Practice Location

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