Provider Demographics
NPI:1790678449
Name:CLARK, MICHEYLA NICOLE (BCBA, COBA)
Entity type:Individual
Prefix:MS
First Name:MICHEYLA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA, COBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 CHESTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8988
Mailing Address - Country:US
Mailing Address - Phone:216-253-5180
Mailing Address - Fax:
Practice Address - Street 1:5700 BLAZER PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3665
Practice Address - Country:US
Practice Address - Phone:800-931-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-25-78965103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst