Provider Demographics
NPI:1104323229
Name:CLARKE, REBECCA (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 FAR HILLS AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2317
Mailing Address - Country:US
Mailing Address - Phone:937-204-3322
Mailing Address - Fax:
Practice Address - Street 1:5335 FAR HILLS AVE STE 109
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2317
Practice Address - Country:US
Practice Address - Phone:937-204-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08595103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist