Provider Demographics
NPI:1629410170
Name:CLARK, LAUREN MARIE (MSW, LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4305
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-1305
Mailing Address - Country:US
Mailing Address - Phone:910-791-1057
Mailing Address - Fax:910-791-2441
Practice Address - Street 1:1401 S 39TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6703
Practice Address - Country:US
Practice Address - Phone:910-791-1057
Practice Address - Fax:910-791-2441
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0082811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical