Provider Demographics
NPI:1023363546
Name:CLARK, CATHARINE (MA, LDN, CNS)
Entity Type:Individual
Prefix:
First Name:CATHARINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LDN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3211
Mailing Address - Country:US
Mailing Address - Phone:301-695-1114
Mailing Address - Fax:
Practice Address - Street 1:2535 WATERSIDE DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3211
Practice Address - Country:US
Practice Address - Phone:301-695-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2904133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46-0575525OtherIRS
MDDX2904OtherSTATE LICENSE (LDN)