Provider Demographics
NPI:1740990639
Name:CLARK, SEAN-ROBERT BEETON
Entity type:Individual
Prefix:
First Name:SEAN-ROBERT
Middle Name:BEETON
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:CLARKS@CHILDRENSGUILD.ORG
Mailing Address - Street 2:6802 MCCLEAN BLVD,
Mailing Address - City:BALITMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-7260
Mailing Address - Country:US
Mailing Address - Phone:410-444-3800
Mailing Address - Fax:
Practice Address - Street 1:CLARKS@CHILDRENSGUILD.ORG
Practice Address - Street 2:6802 MCCLEAN BLVD,
Practice Address - City:BALITMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-7260
Practice Address - Country:US
Practice Address - Phone:410-444-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD264391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD26439Medicaid