Provider Demographics
NPI:1386459089
Name:CLARK, EMILEE RAE (LGPC)
Entity type:Individual
Prefix:
First Name:EMILEE
Middle Name:RAE
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 1:20 SOMERSET RD
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1938
Mailing Address - Country:US
Mailing Address - Phone:717-658-5559
Mailing Address - Fax:
Practice Address - Street 1:7310 RITCHIE HWY STE 1009
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3398
Practice Address - Country:US
Practice Address - Phone:410-768-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health