Provider Demographics
NPI:1316527542
Name:CLARK, BENJAMIN RYAN (LPC)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:RYAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 MARSALA CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1605
Mailing Address - Country:US
Mailing Address - Phone:304-940-9724
Mailing Address - Fax:
Practice Address - Street 1:2501 HUNTER PL STE 202
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3940
Practice Address - Country:US
Practice Address - Phone:304-940-9724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional