Provider Demographics
NPI:1487635132
Name:CLARK, DONALD L (EDD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-0502
Mailing Address - Country:US
Mailing Address - Phone:828-264-6576
Mailing Address - Fax:828-262-9887
Practice Address - Street 1:428 COFFEY KNOB RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-6608
Practice Address - Country:US
Practice Address - Phone:828-264-6576
Practice Address - Fax:828-262-9887
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0431103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist