Provider Demographics
NPI:1124685805
Name:CLARK, RACHEAL (PHD, BCBA)
Entity type:Individual
Prefix:
First Name:RACHEAL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 DAYLONG LN STE 103
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1631
Mailing Address - Country:US
Mailing Address - Phone:410-531-8100
Mailing Address - Fax:
Practice Address - Street 1:6100 DAYLONG LN STE 103
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1631
Practice Address - Country:US
Practice Address - Phone:410-531-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD06447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program