Provider Demographics
NPI:1174026298
Name:CLARK, ANTHONY JAMAL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMAL
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 NC HIGHWAY 42 W STE C
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-7735
Mailing Address - Country:US
Mailing Address - Phone:919-413-8449
Mailing Address - Fax:
Practice Address - Street 1:2301 MONTGOMERY DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4476
Practice Address - Country:US
Practice Address - Phone:252-360-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist