Provider Demographics
NPI:1629256185
Name:CLARK, HOLLY ANN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6232
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:220 E FIRST AVE EXTENSION
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292
Practice Address - Country:US
Practice Address - Phone:336-242-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor