Provider Demographics
NPI:1730548074
Name:CLARK, TONI (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8285 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2468
Mailing Address - Country:US
Mailing Address - Phone:844-854-6878
Mailing Address - Fax:
Practice Address - Street 1:8283 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2032
Practice Address - Country:US
Practice Address - Phone:810-321-3018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000780103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst