Provider Demographics
NPI:1780278390
Name:CLARKE, NICHOLE ASHLEY (TLMFT)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ASHLEY
Last Name:CLARKE
Suffix:
Gender:F
Credentials:TLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 1ST AVE NE STE 30
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4832
Mailing Address - Country:US
Mailing Address - Phone:319-200-5104
Mailing Address - Fax:319-200-2516
Practice Address - Street 1:3812 CEDAR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-6260
Practice Address - Country:US
Practice Address - Phone:319-260-2149
Practice Address - Fax:319-200-2516
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA100708106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist