Provider Demographics
NPI:1134137201
Name:ROBERTS-CLARKE, IVORY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:IVORY
Middle Name:M
Last Name:ROBERTS-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 1:500 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2322
Mailing Address - Country:US
Mailing Address - Phone:617-287-8000
Mailing Address - Fax:
Practice Address - Street 1:500 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02125-2322
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10446103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical