Provider Demographics
NPI:1588866834
Name:CLARKE, BRENDAN JAMES
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:JAMES
Last Name:CLARKE
Suffix:
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 1:26 WARWICK ST # 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-3510
Mailing Address - Country:US
Mailing Address - Phone:617-501-5633
Mailing Address - Fax:
Practice Address - Street 1:206 N MYERS ST APT B
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2323
Practice Address - Country:US
Practice Address - Phone:617-501-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2023-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALPCC14461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health