Provider Demographics
NPI:1548618820
Name:CLARKE, BURLEIGH
Entity Type:Individual
Prefix:
First Name:BURLEIGH
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 LASALLE AVE.
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509
Mailing Address - Country:US
Mailing Address - Phone:757-626-0076
Mailing Address - Fax:
Practice Address - Street 1:1806 LASALLE AVE.
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509
Practice Address - Country:US
Practice Address - Phone:757-626-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist