Provider Demographics
NPI:1194561092
Name:CLARK, TINA (LGPC)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 COOKS LN APT 3B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1285
Mailing Address - Country:US
Mailing Address - Phone:443-629-9985
Mailing Address - Fax:
Practice Address - Street 1:1826 WOODLAWN DR STE 3
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:MD
Practice Address - Zip Code:21207-4050
Practice Address - Country:US
Practice Address - Phone:410-800-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional