Provider Demographics
NPI:1750124939
Name:CLARKE, KEISHA NICOLE
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:NICOLE
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 1:101 ELM AVE APT 4D
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2333
Mailing Address - Country:US
Mailing Address - Phone:914-843-9831
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE APT 4D
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2333
Practice Address - Country:US
Practice Address - Phone:914-843-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral