Basic Information
| Provider Information | |||||||||
| NPI: | 1043460173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | P-LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 FIRST ST W | ||||||||
| Address2: | |||||||||
| City: | AHOSKIE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279108842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522098932 | ||||||||
| FaxNumber: | 2522098933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 FIRST ST W | ||||||||
| Address2: | |||||||||
| City: | AHOSKIE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279108842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522098932 | ||||||||
| FaxNumber: | 2522098933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | P003721 | NC | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.