Provider Demographics
NPI:1962290635
Name:CLARK, ELEXUS KRISTINA
Entity type:Individual
Prefix:
First Name:ELEXUS
Middle Name:KRISTINA
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 1:3132 MONTANA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60088-1551
Mailing Address - Country:US
Mailing Address - Phone:757-389-3419
Mailing Address - Fax:
Practice Address - Street 1:3132 MONTANA AVE APT A
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60088-1551
Practice Address - Country:US
Practice Address - Phone:757-389-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician