Provider Demographics
NPI:1861688053
Name:CLARK, TERRY JAMES (CSC-AD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3402
Mailing Address - Country:US
Mailing Address - Phone:410-837-5533
Mailing Address - Fax:410-837-2168
Practice Address - Street 1:111 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3402
Practice Address - Country:US
Practice Address - Phone:410-837-5533
Practice Address - Fax:410-837-2168
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC0551101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)