Provider Demographics
NPI:1417776527
Name:CLARK, KRISTINA MCNEIL
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MCNEIL
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 THAYER CTR STE C
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1139
Mailing Address - Country:US
Mailing Address - Phone:240-398-6112
Mailing Address - Fax:
Practice Address - Street 1:2040 ALICE AVE
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3576
Practice Address - Country:US
Practice Address - Phone:240-273-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health