Provider Demographics
NPI:1104241934
Name:CLARKE, LESLIE (LCSW-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 E WEST HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4538
Mailing Address - Country:US
Mailing Address - Phone:301-657-4329
Mailing Address - Fax:
Practice Address - Street 1:4401 E WEST HWY STE 300
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4538
Practice Address - Country:US
Practice Address - Phone:301-646-1298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD206391041C0700X
PABH000071103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1770529869OtherMEDICARE