Provider Demographics
NPI:1891321287
Name:CLARKE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 WHISPER BREEZE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-3524
Mailing Address - Country:US
Mailing Address - Phone:210-268-4210
Mailing Address - Fax:
Practice Address - Street 1:9901 W IH 10 STE 775
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1781
Practice Address - Country:US
Practice Address - Phone:210-957-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203074106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor