Provider Demographics
NPI:1376077255
Name:CLARK, BECKY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 TILGHMAN DR
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5507
Mailing Address - Country:US
Mailing Address - Phone:910-249-4219
Mailing Address - Fax:
Practice Address - Street 1:731 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5507
Practice Address - Country:US
Practice Address - Phone:910-249-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0046061041C0700X
NC1041C0700251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health