Provider Demographics
NPI:1427714328
Name:CLARK, KAITLYN (MA, BC-DMT)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, BC-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 INDIAN QUEEN LN UNIT B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1525
Mailing Address - Country:US
Mailing Address - Phone:267-243-3422
Mailing Address - Fax:
Practice Address - Street 1:110 HOPEWELL RD STE 220
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-1047
Practice Address - Country:US
Practice Address - Phone:610-723-8176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional