Provider Demographics
NPI:1811263759
Name:CLARK, TIANA (QP, MA, CRC, LPCA)
Entity type:Individual
Prefix:MRS
First Name:TIANA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:QP, MA, CRC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 DURHAM CHAPEL HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2829
Mailing Address - Country:US
Mailing Address - Phone:919-251-9001
Mailing Address - Fax:919-251-9008
Practice Address - Street 1:2670 DURHAM CHAPEL HILL BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2829
Practice Address - Country:US
Practice Address - Phone:919-251-9001
Practice Address - Fax:919-251-9008
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health