Provider Demographics
NPI:1740938844
Name:CLARKE, TERRY (LCDC)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 PARKER LN APT 266
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-6972
Mailing Address - Country:US
Mailing Address - Phone:325-763-8994
Mailing Address - Fax:
Practice Address - Street 1:1110 W WILLIAM CANNON DR STE 303
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3188
Practice Address - Country:US
Practice Address - Phone:512-899-2100
Practice Address - Fax:512-899-2205
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15547101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)