Provider Demographics
NPI:1306388293
Name:CLARK, CHANNING (LCPC)
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 TEAL WING CT
Mailing Address - Street 2:104
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4806 TEAL WING CT
Practice Address - Street 2:104
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2120
Practice Address - Country:US
Practice Address - Phone:301-254-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCPC7470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health