Provider Demographics
NPI:1245851104
Name:CLARK, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:7900 SCULLY CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-8268
Mailing Address - Country:US
Mailing Address - Phone:703-477-4830
Mailing Address - Fax:
Practice Address - Street 1:10615 JUDICIAL DR STE 403
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7501
Practice Address - Country:US
Practice Address - Phone:703-565-3783
Practice Address - Fax:571-285-4001
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty