Provider Demographics
NPI:1154154516
Name:CLARK, ABAGAIL M
Entity type:Individual
Prefix:
First Name:ABAGAIL
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 STATE RD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9796
Mailing Address - Country:US
Mailing Address - Phone:330-697-5279
Mailing Address - Fax:
Practice Address - Street 1:7710 STATE RD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9796
Practice Address - Country:US
Practice Address - Phone:330-697-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services