Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003158569 |
---|---|
Provider Name | Ebony Clark |
First Address | Las Vegas, NV 89119-4480 |
Second Address | Las Vegas, NV 89119-4480 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2013 |
Last Update Date | 22/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1164669479 | (05) | NV |