Provider Demographics
NPI:1962362467
Name:CLARK, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PRIVET WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9204
Mailing Address - Country:US
Mailing Address - Phone:352-857-7630
Mailing Address - Fax:
Practice Address - Street 1:1000 PRIVET WAY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9204
Practice Address - Country:US
Practice Address - Phone:352-857-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician