Provider Demographics
NPI:1174893945
Name:CLARK, PAUL G (LCSW)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4422
Mailing Address - Country:US
Mailing Address - Phone:703-993-2737
Mailing Address - Fax:
Practice Address - Street 1:1 GOLD LEAF WALK WAY
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2804
Practice Address - Country:US
Practice Address - Phone:703-740-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00028361041C0700X
VA0904-0013621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical