Provider Demographics
NPI:1003511072
Name:CLARK, ALEC COLE
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:COLE
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15048 14TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523-2503
Mailing Address - Country:US
Mailing Address - Phone:352-232-8997
Mailing Address - Fax:833-422-0029
Practice Address - Street 1:15048 14TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-2503
Practice Address - Country:US
Practice Address - Phone:352-232-8997
Practice Address - Fax:833-422-0029
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-5055207T00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery