Provider Demographics
NPI:1902507437
Name:CLARK, ASHTON (BCBA)
Entity Type:Individual
Prefix:
First Name:ASHTON
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 1:12814 CARDINAL GLEN DR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:IN
Mailing Address - Zip Code:46932-7200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 E HOFFER ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2474
Practice Address - Country:US
Practice Address - Phone:765-419-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-23-64584103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst