Provider Demographics
NPI:1750622627
Name:CLARK, RALPH O (LMFT, LPCA)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:O
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMFT, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 MAIDSTONE LN
Mailing Address - Street 2:APT A
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-2760
Mailing Address - Country:US
Mailing Address - Phone:757-814-8922
Mailing Address - Fax:
Practice Address - Street 1:2525 RAEFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5091
Practice Address - Country:US
Practice Address - Phone:757-814-8922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-02
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1551106H00000X
NCA10090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional