Provider Demographics
NPI:1851576789
Name:CLARK, LADONNA M (MA, LCAS)
Entity Type:Individual
Prefix:MS
First Name:LADONNA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 NEW BERN AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1248
Mailing Address - Country:US
Mailing Address - Phone:919-212-8156
Mailing Address - Fax:919-212-8158
Practice Address - Street 1:2949 NEW BERN AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1248
Practice Address - Country:US
Practice Address - Phone:919-212-8156
Practice Address - Fax:919-212-8158
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-92952106S00000X
NC1216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician