Provider Demographics
NPI:1588620538
Name:CLARK, GWENDOLYN D (LCSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 HOLIDAY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3514
Mailing Address - Country:US
Mailing Address - Phone:910-612-0782
Mailing Address - Fax:
Practice Address - Street 1:218 HOLIDAY HILLS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-3514
Practice Address - Country:US
Practice Address - Phone:910-612-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC002055101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106158Medicaid
NC1312UOtherBCBS #
NCC002055OtherLICENSE