Provider Demographics
NPI:1124829775
Name:CLARK, EBONEE MONIQUE (LCMHCA)
Entity type:Individual
Prefix:
First Name:EBONEE
Middle Name:MONIQUE
Last Name:CLARK
Suffix:
Gender:
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 CHANNING PARK CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-7641
Mailing Address - Country:US
Mailing Address - Phone:318-816-0462
Mailing Address - Fax:
Practice Address - Street 1:300 ASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8682
Practice Address - Country:US
Practice Address - Phone:866-272-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21186101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health