Healthcare Provider Details

I. General information

NPI: 1649193178
Provider Name (Legal Business Name): CLARISSA CLARKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 3RD ST SW
ROANOKE VA
24016-5205
US

IV. Provider business mailing address

3214 ELECTRIC RD. STE. 102 - PMB 333
ROANOKE VA
24018
US

V. Phone/Fax

Practice location:
  • Phone: 540-339-6362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019021047
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: