Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1013281559 |
---|---|
Provider Name | Kejuan Patrick Clark |
First Address | Las Vegas, NV 89130-3180 |
Second Address | Las Vegas, NV 89130-3180 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2012 |
Last Update Date | 01/03/2012 |