Provider Demographics
NPI:1417381732
Name:CRAWFORD-CLARK, BRENDA (LMHC, LMFT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:CRAWFORD-CLARK
Suffix:
Gender:F
Credentials:LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 46458
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33646-0104
Mailing Address - Country:US
Mailing Address - Phone:813-504-0360
Mailing Address - Fax:
Practice Address - Street 1:8907 REGENTS PARK DR
Practice Address - Street 2:SUITE 310
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3401
Practice Address - Country:US
Practice Address - Phone:813-504-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC 5109101YP2500X
FLLMFT 1808106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist