Provider Demographics
NPI:1144467259
Name:CLARK, ALLISON KUTNER (MED, BCBA)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:KUTNER
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 BEVAN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4812
Mailing Address - Country:US
Mailing Address - Phone:703-400-3035
Mailing Address - Fax:
Practice Address - Street 1:3705 BEVAN DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4812
Practice Address - Country:US
Practice Address - Phone:703-400-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1084301103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst