Provider Demographics
NPI:1962800516
Name:CLARK, JAMES (BCBA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 SOUTHBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2566
Mailing Address - Country:US
Mailing Address - Phone:774-243-1179
Mailing Address - Fax:774-243-1189
Practice Address - Street 1:65 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2566
Practice Address - Country:US
Practice Address - Phone:774-243-1179
Practice Address - Fax:774-243-1189
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-12-12285103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst