Provider Demographics
NPI:1538630223
Name:CLARK, HOLLY LYN (BCBA 1-18-32061)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:LYN
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA 1-18-32061
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:LYN
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 GREENWOOD ST STE A
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1767
Mailing Address - Country:US
Mailing Address - Phone:508-363-0200
Mailing Address - Fax:
Practice Address - Street 1:345 GREENWOOD ST STE A
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1767
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:508-363-1213
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist