Provider Demographics
NPI:1558333104
Name:CLARK, KAY FREEMAN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KAY
Middle Name:FREEMAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 BRYANS PLACE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5006
Mailing Address - Country:US
Mailing Address - Phone:336-765-7716
Mailing Address - Fax:
Practice Address - Street 1:122 N SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2734
Practice Address - Country:US
Practice Address - Phone:336-774-3988
Practice Address - Fax:336-774-3989
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0016901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002900Medicaid