Provider Demographics
NPI:1912715095
Name:CLARK, ANGELA G
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:G
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 W KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8948
Mailing Address - Country:US
Mailing Address - Phone:918-994-2764
Mailing Address - Fax:
Practice Address - Street 1:6111 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6100
Practice Address - Country:US
Practice Address - Phone:918-779-7216
Practice Address - Fax:918-663-0203
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician