Healthcare Provider Details

I. General information

NPI: 1912113689
Provider Name (Legal Business Name): CHARMAINE CLARKE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 GLEN COVE AVE
GLEN COVE NY
11542-3438
US

IV. Provider business mailing address

795 FULLERTON AVE
UNIONDALE NY
11553-2813
US

V. Phone/Fax

Practice location:
  • Phone: 516-676-2388
  • Fax: 516-759-5259
Mailing address:
  • Phone: 516-676-2388
  • Fax: 516-759-5259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0682941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: