Provider Demographics
NPI:1801380738
Name:CLARKE, BRIAN JOSEPH (LAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:CLARKE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E SOUTHERN AVE STE 735
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 S MCCLINTOCK DR STE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17185101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health