MEDICARE: KIMARA CLARKE LPC-MHSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2044	TN

General Provider Information

NPI Number	:	1568718047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMARA CLARKE LPC-MHSP

Provider Business Mailing Address
First Line	:	755 SAINT ANDREWS DR
Second Line	:	APT. 13-208
City	:	MURFREESBORO
State	:	TN
Zip	:	37128-6537
Country	:	US
Telephone Number	:	931-217-9010
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 SAINT ANDREWS DR
Second Line	:	APT. 13-208
City	:	MURFREESBORO
State	:	TN
Zip	:	37128-6537
Country	:	US
Telephone Number	:	931-217-9010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2012
Last Update Date	:	08/02/2012

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