Provider Demographics
NPI:1508908427
Name:CLARK, RONALD AUSTIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:AUSTIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17719 DEVEAU CT
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132
Mailing Address - Country:US
Mailing Address - Phone:540-338-6940
Mailing Address - Fax:703-771-7556
Practice Address - Street 1:215 LOUDOUN ST SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3115
Practice Address - Country:US
Practice Address - Phone:703-771-7555
Practice Address - Fax:703-771-7556
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040007361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA107637Medicare UPIN