Provider Demographics
NPI:1811229362
Name:CLARK, VIVIAN AUDREY (LCSW,LISW-CP)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:AUDREY
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW,LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 J N PEASE PL STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4541
Mailing Address - Country:US
Mailing Address - Phone:704-907-8242
Mailing Address - Fax:704-973-0694
Practice Address - Street 1:1935 J N PEASE PL STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-907-8242
Practice Address - Fax:704-973-0694
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSW.11115CP1041C0700X, 1041C0700X
NC2850-A101YA0400X
1041C0700X, 1041C0700X
NCC0092921041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)