Provider Demographics
NPI:1053593764
Name:CLARK, ASHLEY LEWIS (MAC, LAC)
Entity type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:LEWIS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 FREDERICK RD
Mailing Address - Street 2:SUITE 101-B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4780
Mailing Address - Country:US
Mailing Address - Phone:410-455-0669
Mailing Address - Fax:
Practice Address - Street 1:611 FREDERICK RD
Practice Address - Street 2:SUITE 101-B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4780
Practice Address - Country:US
Practice Address - Phone:410-455-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01521171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist