Provider Demographics
NPI:1053888925
Name:CLARK, THEODORE RONALD JR
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:RONALD
Last Name:CLARK
Suffix:JR
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 1:1312 NW 96TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-2618
Mailing Address - Country:US
Mailing Address - Phone:786-320-0262
Mailing Address - Fax:
Practice Address - Street 1:1312 NW 96TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-2618
Practice Address - Country:US
Practice Address - Phone:786-320-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician