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General NPI Number Information
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NPI Number | 1558804690
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Entity Type | Individual
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Provider Name | CHARITY ANN CLARK
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Gender | Female
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Dates
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Enumeration Date | 11/21/2016
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Last Update Date | 11/21/2016
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Provider Practice Location Address
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Address Line | 2400 S RIDGEWOOD AVE
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City | SOUTH DAYTONA
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State | FL
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Zip | 32119-3097
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Country | US
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Telephone | 386-304-7600
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Fax |
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Provider Business Mailing Address
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Address Line | 2066 OAK MEADOW CIR
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City | SOUTH DAYTONA
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State | FL
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Zip | 32119-8821
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Country | US
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Telephone | 207-570-2552
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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