Provider Demographics
NPI:1568233955
Name:DAVIES-CLARK, ISAACBA (LGPC)
Entity Type:Individual
Prefix:
First Name:ISAACBA
Middle Name:
Last Name:DAVIES-CLARK
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 E SWAN CREEK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5250
Mailing Address - Country:US
Mailing Address - Phone:240-813-0015
Mailing Address - Fax:
Practice Address - Street 1:17003 MADRILLON WAY
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607-3462
Practice Address - Country:US
Practice Address - Phone:301-437-9268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC200001639101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health