Provider Demographics
NPI:1326652710
Name:CLAY-BENNETT, MYRACLE JEWEL (LCMHC)
Entity Type:Individual
Prefix:
First Name:MYRACLE
Middle Name:JEWEL
Last Name:CLAY-BENNETT
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 S MIAMI BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8025
Mailing Address - Country:US
Mailing Address - Phone:919-358-3012
Mailing Address - Fax:
Practice Address - Street 1:2933 S MIAMI BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8025
Practice Address - Country:US
Practice Address - Phone:706-251-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional