Provider Demographics
NPI:1588376966
Name:CLARK, ANITA (LISW-S, LCSW)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LISW-S, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 FALL PL
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4107
Mailing Address - Country:US
Mailing Address - Phone:740-361-5453
Mailing Address - Fax:
Practice Address - Street 1:811 FALL PL
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4107
Practice Address - Country:US
Practice Address - Phone:740-361-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21028541041C0700X
VA09040158511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical