Provider Demographics
NPI:1932798261
Name:MARTIN, STEPHANIE CLARK (LICSW, LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CLARK
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RUTH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:5709 CEDAR WALK APT 201
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-4528
Mailing Address - Country:US
Mailing Address - Phone:256-762-5915
Mailing Address - Fax:
Practice Address - Street 1:10615 JUDICIAL DR STE 301
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:703-402-2091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500796741041C0700X
VA09040120931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical