Provider Demographics
NPI:1437697836
Name:CLARK, MEGAN MONTGOMERY (MACC, LPCA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MONTGOMERY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MACC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 STILL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-1643
Mailing Address - Country:US
Mailing Address - Phone:704-780-3788
Mailing Address - Fax:704-899-9996
Practice Address - Street 1:4232 SHOPTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3016
Practice Address - Country:US
Practice Address - Phone:704-780-3788
Practice Address - Fax:704-899-9996
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12777101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional