Provider Demographics
NPI:1902625916
Name:CLARK, TAMIKA SHANTAI (LMSW)
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:SHANTAI
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9614 GRANDHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5268
Mailing Address - Country:US
Mailing Address - Phone:301-938-6927
Mailing Address - Fax:
Practice Address - Street 1:1330 MCCORMICK DR.
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774
Practice Address - Country:US
Practice Address - Phone:301-772-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG131081041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool