Provider Demographics
NPI:1912648478
Name:CLINTON, DIAMOND R
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:R
Last Name:CLINTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 W SUGAR CREEK RD STE 203
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-6102
Mailing Address - Country:US
Mailing Address - Phone:980-875-9473
Mailing Address - Fax:704-595-7155
Practice Address - Street 1:537 W SUGAR CREEK RD STE 203
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6102
Practice Address - Country:US
Practice Address - Phone:980-875-9473
Practice Address - Fax:704-595-7155
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC29950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician