MEDICARE: RALPH O CLARK LMFT, LPCA

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
1	106H00000X	Marriage & Family Therapist	1551	NC
2	101YP2500X	Professional Counselor	A10090	NC

General Provider Information

NPI Number	:	1750622627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RALPH O CLARK LMFT, LPCA

Provider Business Mailing Address
First Line	:	5905 MAIDSTONE LN
Second Line	:	APT A
City	:	HOPE MILLS
State	:	NC
Zip	:	28348-2760
Country	:	US
Telephone Number	:	757-814-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 RAEFORD RD
Second Line	:	SUITE B
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5091
Country	:	US
Telephone Number	:	757-814-8922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2013
Last Update Date	:	12/22/2015

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