Provider Demographics
NPI:1992890354
Name:CLARK, LAURA M (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JOHN UMSTEAD HOSPITAL
Mailing Address - Street 2:1003 12TH STREET
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509
Mailing Address - Country:US
Mailing Address - Phone:919-575-7082
Mailing Address - Fax:919-575-7395
Practice Address - Street 1:JOHN UMSTEAD HOSPITAL
Practice Address - Street 2:1003 12TH STREET
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509
Practice Address - Country:US
Practice Address - Phone:919-575-7082
Practice Address - Fax:919-575-7395
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1848103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical