Provider Demographics
NPI:1407743206
Name:CLARK, CHANTELL LEE' PATRICE
Entity type:Individual
Prefix:
First Name:CHANTELL
Middle Name:LEE' PATRICE
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 1:3655 PRAIRIE WATERS DR APT 6109
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7188
Mailing Address - Country:US
Mailing Address - Phone:908-613-2428
Mailing Address - Fax:908-613-2428
Practice Address - Street 1:3655 PRAIRIE WATERS DR APT 6109
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7188
Practice Address - Country:US
Practice Address - Phone:908-613-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician