Provider Demographics
NPI:1336708502
Name:CLUCK, CHELSEA DAWN
Entity Type:Individual
Prefix:MISS
First Name:CHELSEA
Middle Name:DAWN
Last Name:CLUCK
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 1:10410 ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3616
Mailing Address - Country:US
Mailing Address - Phone:785-741-4984
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD STE 600
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4389
Practice Address - Country:US
Practice Address - Phone:703-582-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst