Provider Demographics
NPI:1710632278
Name:CLARK, DEREK ELLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ELLIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 MONUMENT CT UNIT 204
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2878
Mailing Address - Country:US
Mailing Address - Phone:703-424-6788
Mailing Address - Fax:
Practice Address - Street 1:4100 MONUMENT CT UNIT 204
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2878
Practice Address - Country:US
Practice Address - Phone:571-393-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040137101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical