Provider Demographics
NPI:1831725472
Name:CLARKE, TALESIA
Entity type:Individual
Prefix:
First Name:TALESIA
Middle Name:
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 1:6701 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-1338
Mailing Address - Country:US
Mailing Address - Phone:813-846-5579
Mailing Address - Fax:
Practice Address - Street 1:6701 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-1338
Practice Address - Country:US
Practice Address - Phone:813-846-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities