Provider Demographics
NPI:1902307242
Name:CLARK, MIKAELA KURIN (PSY)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:KURIN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5057 GABLE CREST CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3880
Mailing Address - Country:US
Mailing Address - Phone:808-342-7392
Mailing Address - Fax:702-992-0326
Practice Address - Street 1:2110 LOS FELIZ ST UNIT 2072
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-8026
Practice Address - Country:US
Practice Address - Phone:702-808-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X, 103T00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist