Provider Demographics
NPI:1477726404
Name:CLARKE, BEVERLY MAE (LADC1)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:MAE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 UNION ST STE B
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1310
Mailing Address - Country:US
Mailing Address - Phone:781-581-9270
Mailing Address - Fax:781-581-8413
Practice Address - Street 1:181 UNION ST STE B
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1310
Practice Address - Country:US
Practice Address - Phone:781-581-9270
Practice Address - Fax:781-581-8413
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)