Provider Demographics
NPI:1124390992
Name:CLARKE, GILDA T (MS)
Entity type:Individual
Prefix:
First Name:GILDA
Middle Name:T
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PARK ST. NE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-281-4928
Mailing Address - Fax:703-242-1454
Practice Address - Street 1:133 PARK ST. NE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-281-4928
Practice Address - Fax:703-242-1454
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health