Provider Demographics
NPI:1972900702
Name:CLARK, DEMEATRIS (MA, LCAS-A)
Entity type:Individual
Prefix:
First Name:DEMEATRIS
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8912 MCMILLIAN DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-8654
Mailing Address - Country:US
Mailing Address - Phone:980-613-2397
Mailing Address - Fax:
Practice Address - Street 1:7925 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3408
Practice Address - Country:US
Practice Address - Phone:704-706-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor