Basic Information
Provider Information | |||||||||
NPI: | 1275966335 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARKE | ||||||||
FirstName: | ASHLEIGH | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OLLILA | ||||||||
OtherFirstName: | ASHLEIGH | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4545 S 86TH ST | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685269262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024836990 | ||||||||
FaxNumber: | 5033975373 | ||||||||
Practice Location | |||||||||
Address1: | 4545 S 86TH ST | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685269262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024836990 | ||||||||
FaxNumber: | 5033975373 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2013 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 693 | NE | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X |   | OR | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.