Provider Demographics
NPI:1447713029
Name:CLARK, DEANNA (BCBA)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17170 MILL FOREST RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4305
Mailing Address - Country:US
Mailing Address - Phone:832-240-4563
Mailing Address - Fax:281-715-5610
Practice Address - Street 1:17170 MILL FOREST RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4305
Practice Address - Country:US
Practice Address - Phone:832-240-4563
Practice Address - Fax:281-715-5610
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16-25093106S00000X
TX1-22-62526103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician