Provider Demographics
NPI:1043835457
Name:CLARKE, KELLY ANNE (MSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MONTROSE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1574
Mailing Address - Country:US
Mailing Address - Phone:215-388-1399
Mailing Address - Fax:
Practice Address - Street 1:AMERICAN TREATMENT NETWORK PHYSICIAN & ASSOCIATES
Practice Address - Street 2:1120 TOWNSHIP LINE ROAD
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083
Practice Address - Country:US
Practice Address - Phone:484-535-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1275189375Medicaid