Provider Demographics
NPI:1033165923
Name:CLARK, KELVIN D (MS, LMFT, LPC, LCAS)
Entity Type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, LMFT, LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-8110
Mailing Address - Country:US
Mailing Address - Phone:919-776-0399
Mailing Address - Fax:910-323-1144
Practice Address - Street 1:1500 BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4289
Practice Address - Country:US
Practice Address - Phone:910-323-1065
Practice Address - Fax:910-323-1144
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC448101Y00000X, 106H00000X
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14762257OtherUNITED HEALTHCARE
NC1002XOtherBLUE CROSS PROVIDER
NC6102267Medicaid
NC11367606OtherCAQH