Healthcare Provider Details

I. General information

NPI: 1265345029
Provider Name (Legal Business Name): MARQUIS RAYNARD CLARKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10106 KRAUSE RD STE 202
CHESTERFIELD VA
23832-6503
US

IV. Provider business mailing address

10106 KRAUSE RD STE 202
CHESTERFIELD VA
23832-6503
US

V. Phone/Fax

Practice location:
  • Phone: 202-469-9095
  • Fax: 804-800-2284
Mailing address:
  • Phone: 202-469-9095
  • Fax: 804-800-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0906017315
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: