=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023765435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL CLARK LCSWA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2022
-----------------------------------------------------
Last Update Date | 03/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3126 MILTON RD STE 232
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-930-0680
-----------------------------------------------------
Fax | 855-655-2688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8640 UNIVERSITY CITY BLVD STE A3153
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-202-2526
-----------------------------------------------------
Fax | 855-655-2688
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P017249
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------