Provider Demographics
NPI:1669551727
Name:CLARK, VICTOR GERARD (LPC)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:GERARD
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 1:330 BARNARD AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28804-3275
Mailing Address - Country:US
Mailing Address - Phone:919-215-7025
Mailing Address - Fax:
Practice Address - Street 1:330 BARNARD AVE STE 2
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-3275
Practice Address - Country:US
Practice Address - Phone:919-215-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103324Medicaid