Provider Demographics
NPI:1659767697
Name:CLARKE, CHANEL MARIE
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:MARIE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANEL
Other - Middle Name:MARIE
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SOCIAL WORKER
Mailing Address - Street 1:7833 BURTHE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-3946
Mailing Address - Country:US
Mailing Address - Phone:504-240-3056
Mailing Address - Fax:
Practice Address - Street 1:10001 LAKE FOREST BLVD
Practice Address - Street 2:SUITE 616
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-6200
Practice Address - Country:US
Practice Address - Phone:504-240-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health