Provider Demographics
NPI:1679011126
Name:SPANN-CLARK, CARMENITA C (LICSW)
Entity Type:Individual
Prefix:
First Name:CARMENITA
Middle Name:C
Last Name:SPANN-CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PELICAN GARTH
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5743
Mailing Address - Country:US
Mailing Address - Phone:202-489-5530
Mailing Address - Fax:
Practice Address - Street 1:5056 KIMI GRAY CT SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-5915
Practice Address - Country:US
Practice Address - Phone:202-556-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-04
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500811371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical