Provider Demographics
NPI:1235146697
Name:CLARK, EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0009
Mailing Address - Country:US
Mailing Address - Phone:910-673-9111
Mailing Address - Fax:910-673-6202
Practice Address - Street 1:121 E ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2947
Practice Address - Country:US
Practice Address - Phone:910-875-8156
Practice Address - Fax:910-875-5579
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0009891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003566Medicaid
NC2864529BMedicare ID - Type Unspecified