MEDICARE: MS. MARY COLLEEN CLARKE MA

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	101YM0800X	Mental Health Counselor		MN

General Provider Information

NPI Number	:	1548122971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY COLLEEN CLARKE MA

Provider Business Mailing Address
First Line	:	2136 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-2850
Country	:	US
Telephone Number	:	612-552-1230
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 CLEVELAND AVE S STE 223
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-3867
Country	:	US
Telephone Number	:	612-552-1230
Fax Number	:

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

Provider Enumeration Date	:	11/24/2025
Last Update Date	:	11/24/2025

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