Provider Demographics
NPI:1306861331
Name:CLARK, JOHN D (MSW, LCSW-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7436
Mailing Address - Country:US
Mailing Address - Phone:410-367-8943
Mailing Address - Fax:
Practice Address - Street 1:10905 FORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5843
Practice Address - Country:US
Practice Address - Phone:301-292-3994
Practice Address - Fax:301-292-4928
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD040541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD018487N75Medicare ID - Type Unspecified