Provider Demographics
NPI:1063054310
Name:CLARKE COUNSELING AND PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:CLARKE COUNSELING AND PSYCHOLOGICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NICKEISHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:813-445-8575
Mailing Address - Street 1:710 OAKFIELD DR STE 153
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4954
Mailing Address - Country:US
Mailing Address - Phone:813-445-8575
Mailing Address - Fax:
Practice Address - Street 1:710 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4938
Practice Address - Country:US
Practice Address - Phone:813-445-8575
Practice Address - Fax:813-649-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1245710904OtherNPI