Provider Demographics
NPI:1730360637
Name:CLARKE, BRIAN LAURENCE (MS, MFT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LAURENCE
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412047
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-9047
Mailing Address - Country:US
Mailing Address - Phone:626-534-5318
Mailing Address - Fax:
Practice Address - Street 1:711 E WALNUT ST
Practice Address - Street 2:SUITE 407
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1676
Practice Address - Country:US
Practice Address - Phone:626-534-5318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 48784106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist