Provider Demographics
NPI:1659829752
Name:CLARK, CORY (MED, NCC, LPC-A)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MED, NCC, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 EXECUTIVE CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4589
Mailing Address - Country:US
Mailing Address - Phone:919-462-8308
Mailing Address - Fax:919-462-0433
Practice Address - Street 1:1151 EXECUTIVE CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4589
Practice Address - Country:US
Practice Address - Phone:919-462-8308
Practice Address - Fax:919-462-0433
Is Sole Proprietor?:No
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12434101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional