Healthcare Provider Details

I. General information

NPI: 1770945552
Provider Name (Legal Business Name): MARILYN CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CREIGHTON AVE
RONKONKOMA NY
11779-4416
US

IV. Provider business mailing address

950 S OYSTER BAY RD
HICKSVILLE NY
11801-3510
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-2260
  • Fax:
Mailing address:
  • Phone: 516-822-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: