Provider Demographics
NPI:1689170011
Name:CLARK, CARMENTA
Entity Type:Individual
Prefix:
First Name:CARMENTA
Middle Name:
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 1:2401 HARTMAN ST # F
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-2458
Mailing Address - Country:US
Mailing Address - Phone:804-343-6500
Mailing Address - Fax:
Practice Address - Street 1:2401 HARTMAN ST # F
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2458
Practice Address - Country:US
Practice Address - Phone:804-343-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool