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NPI Code Detail

MEDICARE: WANDA MAE CLARK

MEDICARE: WANDA MAE CLARK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor13049691-6004UT
2101YP2500XProfessional CounselorLPC012942GA
3101YM0800XMental Health Counselor12159NC

General Provider Information

NPI Number : 1376866301
Entity Type Code : Individual
Provider Name (Legal Business Name) : WANDA MAE CLARK
Provider Business Mailing Address
First Line : 284 EXECUTIVE PARK DR
Second Line : SUITE 100
City : CONCORD
State : NC
Zip : 28025-1831
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3424 PEACHTREE RD NE STE 2200
Second Line :
City : ATLANTA
State : GA
Zip : 30326-1156
Country : US
Telephone Number : 323-205-7088
Fax Number : 833-419-0181
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/04/2010
Last Update Date : 03/12/2026

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Directions to “ WANDA MAE CLARK ” Practice Location

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