Provider Demographics
NPI:1538039995
Name:CLARK, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
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 1:6961 ROOKS CT APT 202
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2780
Mailing Address - Country:US
Mailing Address - Phone:845-705-4066
Mailing Address - Fax:
Practice Address - Street 1:5970 FREDERICK CROSSING LN STE 100
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-5176
Practice Address - Country:US
Practice Address - Phone:240-415-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical