Provider Demographics
NPI:1477855260
Name:CLARKE, LARRY ISAIAH (QMHA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ISAIAH
Last Name:CLARKE
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 S PECOS RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1960
Mailing Address - Country:US
Mailing Address - Phone:702-538-9474
Mailing Address - Fax:702-834-8437
Practice Address - Street 1:5860 S PECOS RD
Practice Address - Street 2:STE. 300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-5428
Practice Address - Country:US
Practice Address - Phone:702-538-9474
Practice Address - Fax:702-834-8437
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1316279185Medicaid