Provider Demographics
NPI:1346616208
Name:CLARKE, KEITH ANDREW (CPT, CMT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ANDREW
Last Name:CLARKE
Suffix:
Gender:M
Credentials:CPT, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W G ST # 819
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6096
Mailing Address - Country:US
Mailing Address - Phone:619-906-7055
Mailing Address - Fax:619-639-8269
Practice Address - Street 1:3975 5TH AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3101
Practice Address - Country:US
Practice Address - Phone:619-906-7055
Practice Address - Fax:619-639-8269
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67117225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA67117OtherCALIFORNIA MASSAGE THERAPY COUNCIL
CA1346616208OtherNPPES