Basic Information
| Provider Information | |||||||||
| NPI: | 1225022551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERRANCE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 BONNIE LN | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287798511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285865501 | ||||||||
| FaxNumber: | 8285863965 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 TIMBERLANE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287867927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284541098 | ||||||||
| FaxNumber: | 8284549242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
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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 | 2084P0800X | MD34832 | TN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 20250 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 89064CV | 05 | NC | MEDICAID |