Basic Information
| Provider Information | |||||||||
| NPI: | 1154822328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SHERYL | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC-A, LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12740 SPRUCE TREE WAY STE 102 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276148295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199161160 | ||||||||
| FaxNumber: | 9194884226 | ||||||||
| Practice Location | |||||||||
| Address1: | 12740 SPRUCE TREE WAY STE 102 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276148295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199161160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | A21708 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | A12269 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.