Provider Demographics
NPI:1932470119
Name:CLARK, LANCE (MA, LCMHC, BCTMH, QS)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MA, LCMHC, BCTMH, QS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N JUDD PKWY NE STE 226
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2624
Mailing Address - Country:US
Mailing Address - Phone:919-812-7535
Mailing Address - Fax:
Practice Address - Street 1:320 N JUDD PKWY NE STE 226
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2624
Practice Address - Country:US
Practice Address - Phone:919-812-7535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9217101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional