Provider Demographics
NPI:1437656824
Name:CLARKE, PATRICIA ELLEN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ELLEN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34-3 SHUNPIKE RD # 196
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2490
Mailing Address - Country:US
Mailing Address - Phone:860-604-6729
Mailing Address - Fax:
Practice Address - Street 1:34-3 SHUNPIKE RD # 196
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2490
Practice Address - Country:US
Practice Address - Phone:860-604-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-17-28526103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst