Provider Demographics
NPI:1295250876
Name:CLARK, BETSY GRIFFEN (LCSW)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:GRIFFEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 MABLE AVE
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-3785
Mailing Address - Country:US
Mailing Address - Phone:704-925-1886
Mailing Address - Fax:
Practice Address - Street 1:1165 MCKEE FARM LN
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-8671
Practice Address - Country:US
Practice Address - Phone:704-771-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0027891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
776OtherBOARD OF ONCOLOGY SOCIAL WORK CERTIFICATION
NCC002789OtherNORTH CAROLINA SOCIAL WORK CERTIFICATION AND LICENSURE BOARD