Provider Demographics
NPI:1831805027
Name:CLARKE, MARDEE
Entity type:Individual
Prefix:
First Name:MARDEE
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 1:5045 W BASELINE RD # 497
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7392
Mailing Address - Country:US
Mailing Address - Phone:480-896-8919
Mailing Address - Fax:
Practice Address - Street 1:5045 W BASELINE RD # 497
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-7392
Practice Address - Country:US
Practice Address - Phone:480-896-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-20575101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health