Provider Demographics
NPI:1740844240
Name:CLARKE, BRYAN THOMAS (RADT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:THOMAS
Last Name:CLARKE
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N QUINCY RD
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-4334
Mailing Address - Country:US
Mailing Address - Phone:209-277-4386
Mailing Address - Fax:
Practice Address - Street 1:3125 MCHENRY AVE STE D
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1451
Practice Address - Country:US
Practice Address - Phone:209-523-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507004599101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)