Provider Demographics
NPI:1518540822
Name:CLARKE, CHARLES (RBT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-1322
Mailing Address - Country:US
Mailing Address - Phone:605-271-2690
Mailing Address - Fax:605-271-3956
Practice Address - Street 1:1101 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-1322
Practice Address - Country:US
Practice Address - Phone:605-271-2690
Practice Address - Fax:605-271-3956
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDRBT-19-106697106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician