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General NPI Number Information
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NPI Number | 1609303312
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Entity Type | Individual
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Provider Name | KRISTA CLARK
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Gender | Female
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Dates
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Enumeration Date | 05/12/2017
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Last Update Date | 09/12/2022
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Provider Practice Location Address
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Address Line | 405 N WASHINGTON ST STE 310
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City | FALLS CHURCH
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State | VA
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Zip | 22046-3460
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Country | US
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Telephone | 703-672-3819
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Fax |
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Provider Business Mailing Address
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Address Line | 405 N WASHINGTON ST STE 310
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City | FALLS CHURCH
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State | VA
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Zip | 22046-3460
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0717001837
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT001706
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | AMFT000469
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License Number State | GA
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