Provider Demographics
NPI:1417002551
Name:CLARK, LAURA L (MS, LCAS)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 MELBOURNE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1826
Mailing Address - Country:US
Mailing Address - Phone:704-665-8564
Mailing Address - Fax:
Practice Address - Street 1:429 BILLINGSLEY ROAD 2ND FLOOR
Practice Address - Street 2:MECKLENBURG COUNTY SUBSTANCE ABUSE SERVICES CENTER
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1098
Practice Address - Country:US
Practice Address - Phone:704-432-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1081101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111895Medicaid