Provider Demographics
NPI:1104615921
Name:CLARK, SHAMIA (LCPC)
Entity type:Individual
Prefix:
First Name:SHAMIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2546
Mailing Address - Country:US
Mailing Address - Phone:443-455-0786
Mailing Address - Fax:
Practice Address - Street 1:3608 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2546
Practice Address - Country:US
Practice Address - Phone:443-455-0786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC15913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health