Individual
KEVIN CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
10615 JUDICIAL DR STE 403, FAIRFAX, VA 22030-7501
(703) 565-3783
(571) 285-4001
Mailing address
7900 SCULLY CT, MANASSAS, VA 20111-8268
(703) 477-4830
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
0710103244
VA
Other
Enumeration date
05/01/2020
Last updated
04/26/2021
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