Basic Information
| Provider Information | |||||||||
| NPI: | 1033386610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLUBINE | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BA, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 HAY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1329 ROBESON ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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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 | 101YA0400X | INTERN | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.