Provider Demographics
NPI:1285124776
Name:CLARKE, KENUATED L (LMHC)
Entity type:Individual
Prefix:
First Name:KENUATED
Middle Name:L
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 MAJESTIC GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-5736
Mailing Address - Country:US
Mailing Address - Phone:863-677-4029
Mailing Address - Fax:
Practice Address - Street 1:602 MELTON AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-4428
Practice Address - Country:US
Practice Address - Phone:863-967-8190
Practice Address - Fax:863-967-8192
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
FL324500000X
FL13722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty