MEDICARE: NICKEISHA CLARKE PSYD

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	PY9310	FL

General Provider Information

NPI Number	:	1245710904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKEISHA CLARKE PSYD

Provider Business Mailing Address
First Line	:	4729 US 98 S STE 104
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33812-4323
Country	:	US
Telephone Number	:	863-877-1855
Fax Number	:	863-646-6111

Provider Business Practice Location Address
First Line	:	4729 US 98 S
Second Line	:	SUITE 104
City	:	LAKELAND
State	:	FL
Zip	:	33812-4323
Country	:	US
Telephone Number	:	863-877-1855
Fax Number	:	863-646-6111

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

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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