Provider Demographics
NPI:1336865708
Name:CLARK, SAMANTHA LEI (LCSWA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LEI
Last Name:CLARK
Suffix:
Gender:
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-703-7003
Mailing Address - Fax:704-865-4614
Practice Address - Street 1:206 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:GROVER
Practice Address - State:NC
Practice Address - Zip Code:28073-9551
Practice Address - Country:US
Practice Address - Phone:704-476-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0169661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical