Healthcare Provider Details

I. General information

NPI: 1689710006
Provider Name (Legal Business Name): BETTY ANN CLARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 AVENSONG CROSSING DR
CHARLOTTE NC
28215-8078
US

IV. Provider business mailing address

9709 AVENSONG CROSSING DR
CHARLOTTE NC
28215-8078
US

V. Phone/Fax

Practice location:
  • Phone: 704-532-1071
  • Fax:
Mailing address:
  • Phone: 704-532-1071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number60001581
License Number StateNC

VIII. Authorized Official

Name: BETTY ANN CLARK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 70453231071