Provider Demographics
NPI:1922354059
Name:CLERGE, KANILINA
Entity Type:Individual
Prefix:
First Name:KANILINA
Middle Name:
Last Name:CLERGE
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 1:867 W BLOOMINGDALE AVE # 6971
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7701
Mailing Address - Country:US
Mailing Address - Phone:863-313-0340
Mailing Address - Fax:
Practice Address - Street 1:867 W BLOOMINGDALE AVE # 6971
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7701
Practice Address - Country:US
Practice Address - Phone:863-313-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLMT4165106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program