Provider Demographics
NPI:1396221255
Name:CLACKS, DWAYNE (CERTIFIED TRAINER)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:CLACKS
Suffix:
Gender:M
Credentials:CERTIFIED TRAINER
Other - Prefix:
Other - First Name:DWAYNE
Other - Middle Name:
Other - Last Name:CLACKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED TRAINER
Mailing Address - Street 1:5703 CYPRESS CREEK DR APT 3
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-1806
Mailing Address - Country:US
Mailing Address - Phone:202-531-0195
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW STE 300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1631
Practice Address - Country:US
Practice Address - Phone:202-531-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty