Provider Demographics
NPI:1942987276
Name:CLARKE, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
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 1:4670 LIPSCOMB ST NE STE 10
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2927
Mailing Address - Country:US
Mailing Address - Phone:813-906-6203
Mailing Address - Fax:813-436-5623
Practice Address - Street 1:4670 LIPSCOMB ST NE STE 10
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2927
Practice Address - Country:US
Practice Address - Phone:813-906-6203
Practice Address - Fax:813-436-5623
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician