Provider Demographics
NPI:1902497977
Name:CLARK, ANTHONY (LCSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3369 ESQUARRE CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1026
Mailing Address - Country:US
Mailing Address - Phone:571-205-0344
Mailing Address - Fax:
Practice Address - Street 1:3369 ESQUARRE CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1026
Practice Address - Country:US
Practice Address - Phone:571-205-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040079491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical