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General NPI Number Information
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NPI Number | 1689710006
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Entity Type | Organization
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Legal Business Name | BETTY ANN CLARK
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9709 AVENSONG CROSSING DR
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City | CHARLOTTE
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State | NC
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Zip | 28215-8078
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Country | US
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Telephone | 704-532-1071
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Fax |
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Provider Business Mailing Address
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Address Line | 9709 AVENSONG CROSSING DR
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City | CHARLOTTE
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State | NC
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Zip | 28215-8078
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Country | US
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Telephone | 704-532-1071
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BETTY ANN CLARK
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Credential |
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Telephone | 70453231071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 60001581
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License Number State | NC
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