Provider Demographics
NPI:1033386610
Name:CLUBINE, LARRY WAYNE (BA, CSAC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:CLUBINE
Suffix:
Gender:M
Credentials:BA, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5313
Mailing Address - Country:US
Mailing Address - Phone:910-438-0939
Mailing Address - Fax:
Practice Address - Street 1:1329 ROBESON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5531
Practice Address - Country:US
Practice Address - Phone:910-438-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCINTERN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)