Provider Demographics
NPI:1558722082
Name:CLARK, COURTNEY (BCBA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-0022
Mailing Address - Country:US
Mailing Address - Phone:603-689-6188
Mailing Address - Fax:
Practice Address - Street 1:176A MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6164
Practice Address - Country:US
Practice Address - Phone:603-689-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1-16-23719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3137577Medicaid