Provider Demographics
NPI:1699489922
Name:CLARK, SKYLOR MAXX (LCSWA)
Entity type:Individual
Prefix:
First Name:SKYLOR
Middle Name:MAXX
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 KAURI CLIFFS DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-3830
Mailing Address - Country:US
Mailing Address - Phone:336-504-4090
Mailing Address - Fax:
Practice Address - Street 1:1117 KAURI CLIFFS DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-3830
Practice Address - Country:US
Practice Address - Phone:336-504-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0168321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical