Basic Information
| Provider Information | |||||||||
| NPI: | 1235146697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | WEST END | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273760009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106739111 | ||||||||
| FaxNumber: | 9106736202 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 E ELWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283762947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108758156 | ||||||||
| FaxNumber: | 9108755579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C000989 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003566 | 05 | NC | MEDICAID |