Provider Demographics
NPI:1821559410
Name:CLARK, DORIAN M
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8967 YELLOW BRICK RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2303
Mailing Address - Country:US
Mailing Address - Phone:433-317-9670
Mailing Address - Fax:
Practice Address - Street 1:8967 YELLOW BRICK RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2303
Practice Address - Country:US
Practice Address - Phone:443-317-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD223151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical