Healthcare Provider Details

I. General information

NPI: 1710893920
Provider Name (Legal Business Name): CIARA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLAIRE CLARK

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9107 HORNER CT
FAIRFAX VA
22031-3838
US

IV. Provider business mailing address

5433 CHESHIRE MEADOWS WAY
FAIRFAX VA
22032-3217
US

V. Phone/Fax

Practice location:
  • Phone: 703-645-6300
  • Fax:
Mailing address:
  • Phone: 845-820-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204001863
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: