Provider Demographics
NPI:1114798683
Name:CLARK, ALISHA SHANTEL (LGPC)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:SHANTEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 JEREMY CT APT A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3062
Mailing Address - Country:US
Mailing Address - Phone:443-226-1966
Mailing Address - Fax:
Practice Address - Street 1:9613 HARFORD RD STE 3
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-2150
Practice Address - Country:US
Practice Address - Phone:410-714-0775
Practice Address - Fax:443-380-2886
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLG14531101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional