Provider Demographics
NPI:1588605125
Name:CLARK, GARY E (LCPC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7529 CINNABAR TER
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-4576
Mailing Address - Country:US
Mailing Address - Phone:301-917-7947
Mailing Address - Fax:
Practice Address - Street 1:7529 CINNABAR TER
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-4576
Practice Address - Country:US
Practice Address - Phone:301-917-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC 0902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD051700300Medicaid