Provider Demographics
NPI:1235955865
Name:CLARK, AMANDA CATHERINE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
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 1:3429 27TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1433
Mailing Address - Country:US
Mailing Address - Phone:262-818-6839
Mailing Address - Fax:
Practice Address - Street 1:536 ATRIUM DR STE 400
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1731
Practice Address - Country:US
Practice Address - Phone:224-676-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst