Provider Demographics
NPI:1831311406
Name:CLARK, TODD (LPC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD
Mailing Address - Street 2:SUITE 200 (FORSYTH MEDICAL GROUP)
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2435
Mailing Address - Fax:336-277-9275
Practice Address - Street 1:3821 FORRESTGATE DRIVE
Practice Address - Street 2:DBA FORSYTH BEHAVIOR HEALTH
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-277-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2636106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist