Healthcare Provider Details

I. General information

NPI: 1194651380
Provider Name (Legal Business Name): MISS MARY KIMBERLY CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7090 SAMUEL MORSE DR STE 100-300
COLUMBIA MD
21046-3442
US

IV. Provider business mailing address

104 BROADVIEW BLVD S
GLEN BURNIE MD
21061-2605
US

V. Phone/Fax

Practice location:
  • Phone: 855-935-3691
  • Fax:
Mailing address:
  • Phone: 443-979-6620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: