Provider Demographics
NPI:1982083721
Name:CLARKE, KRYSTAL LEIGH (MT-BC)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:LEIGH
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:MISS
Other - First Name:KRYSTAL
Other - Middle Name:LEIGH
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19720 MOUTH OF MONOCACY RD
Mailing Address - Street 2:
Mailing Address - City:DICKERSON
Mailing Address - State:MD
Mailing Address - Zip Code:20842-9519
Mailing Address - Country:US
Mailing Address - Phone:301-461-8096
Mailing Address - Fax:
Practice Address - Street 1:19720 MOUTH OF MONOCACY RD
Practice Address - Street 2:
Practice Address - City:DICKERSON
Practice Address - State:MD
Practice Address - Zip Code:20842-9519
Practice Address - Country:US
Practice Address - Phone:301-461-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV225A00000X225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program