MEDICARE: JOHN D CLARK MSW, LCSW-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	04054	MD

General Provider Information

NPI Number	:	1306861331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN D CLARK MSW, LCSW-C

Provider Business Mailing Address
First Line	:	3604 WABASH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-7436
Country	:	US
Telephone Number	:	410-367-8943
Fax Number	:

Provider Business Practice Location Address
First Line	:	10905 FORT WASHINGTON RD
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-5843
Country	:	US
Telephone Number	:	301-292-3994
Fax Number	:	301-292-4928

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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