Provider Demographics
NPI:1730655481
Name:CLARK, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
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 1:300 KIMBERLY WOODS CT
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5915
Mailing Address - Country:US
Mailing Address - Phone:301-509-5252
Mailing Address - Fax:
Practice Address - Street 1:649 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6349
Practice Address - Country:US
Practice Address - Phone:240-651-9432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician