Provider Demographics
NPI:1770744724
Name:CLARKE, MARA MICHELLE SHELLEY (BCBA)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:MICHELLE SHELLEY
Last Name:CLARKE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31511 SADDLE LN
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33543-4772
Mailing Address - Country:US
Mailing Address - Phone:813-780-2375
Mailing Address - Fax:813-779-1530
Practice Address - Street 1:31511 SADDLE LN
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33543-4772
Practice Address - Country:US
Practice Address - Phone:813-780-2375
Practice Address - Fax:813-779-1530
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist