Provider Demographics
NPI:1417679283
Name:CLARK, SANAYA RENEE
Entity Type:Individual
Prefix:
First Name:SANAYA
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22672 CABIN BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-3451
Mailing Address - Country:US
Mailing Address - Phone:301-542-9942
Mailing Address - Fax:
Practice Address - Street 1:5000 THAYER CTR STE COAKLAND
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1139
Practice Address - Country:US
Practice Address - Phone:904-679-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician