Provider Demographics
NPI:1295549079
Name:CLARKE, MICHAEL D (ADT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:CLARKE
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 FAIRBANKS CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1638
Mailing Address - Country:US
Mailing Address - Phone:443-340-4803
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON PARK DR STE 100A
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6140
Practice Address - Country:US
Practice Address - Phone:410-999-0891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT3733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty