Provider Demographics
NPI:1083140438
Name:CLARKE, CAPEN SHAYNE
Entity Type:Individual
Prefix:
First Name:CAPEN
Middle Name:SHAYNE
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 1:4420 DELESPINE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-3552
Mailing Address - Country:US
Mailing Address - Phone:321-795-6818
Mailing Address - Fax:
Practice Address - Street 1:4420 DELESPINE RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-3552
Practice Address - Country:US
Practice Address - Phone:321-795-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 1041C0700X
NCPO171061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor