Provider Demographics
NPI:1437430089
Name:CLARKE, MARY M (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 BELLEVUE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-3409
Mailing Address - Country:US
Mailing Address - Phone:773-988-1621
Mailing Address - Fax:
Practice Address - Street 1:445 BELLEVUE AVE STE 104
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4923
Practice Address - Country:US
Practice Address - Phone:773-417-6693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007617103TC0700X
CA26460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical