MEDICARE: TANA L CLARKE PHD

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	103TC0700X	Clinical Psychologist	04890	MD

General Provider Information

NPI Number	:	1053611749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANA L CLARKE PHD

Provider Business Mailing Address
First Line	:	877 BALTIMORE ANNAPOLIS BLVD STE 202
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-4716
Country	:	US
Telephone Number	:	410-684-3806
Fax Number	:	410-421-8042

Provider Business Practice Location Address
First Line	:	877 BALTIMORE ANNAPOLIS BLVD STE 202
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-4716
Country	:	US
Telephone Number	:	410-684-3806
Fax Number	:	410-821-8042

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

Provider Enumeration Date	:	10/27/2010
Last Update Date	:	06/01/2022

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