Provider Demographics
NPI:1740350081
Name:CLARK, MARILYN FOSTER (LCPC)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:FOSTER
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 PURLINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3406
Mailing Address - Country:US
Mailing Address - Phone:410-435-0868
Mailing Address - Fax:
Practice Address - Street 1:5405 PURLINGTON WAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3406
Practice Address - Country:US
Practice Address - Phone:410-435-8683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0487101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral