Provider Demographics
NPI:1134714595
Name:CLARKE, GDEBANEN (LMHC)
Entity type:Individual
Prefix:
First Name:GDEBANEN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-3735
Mailing Address - Country:US
Mailing Address - Phone:603-856-5057
Mailing Address - Fax:
Practice Address - Street 1:25 WELLMAN AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-1361
Practice Address - Country:US
Practice Address - Phone:978-251-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10001079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health