Provider Demographics
NPI:1922714344
Name:CLARK, TANEASHA
Entity type:Individual
Prefix:
First Name:TANEASHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANEASHA
Other - Middle Name:
Other - Last Name:REDMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4619 MANNASOTA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5716
Mailing Address - Country:US
Mailing Address - Phone:443-635-3000
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW STE 300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1631
Practice Address - Country:US
Practice Address - Phone:202-660-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29463104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker