Provider Demographics
NPI:1386911105
Name:CLARK, VARGAS L (MS ED)
Entity type:Individual
Prefix:MR
First Name:VARGAS
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 THORNBURY CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9591
Mailing Address - Country:US
Mailing Address - Phone:901-216-1486
Mailing Address - Fax:
Practice Address - Street 1:4813 THORNBURY CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9591
Practice Address - Country:US
Practice Address - Phone:901-216-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst