Provider Demographics
NPI:1730938887
Name:WHITE CLARK, COURTNEY (LCMHC, NBC-HWC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WHITE CLARK
Suffix:
Gender:F
Credentials:LCMHC, NBC-HWC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:216 OSWEGO CT
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8662
Mailing Address - Country:US
Mailing Address - Phone:252-377-7138
Mailing Address - Fax:
Practice Address - Street 1:508 FULTON ST # 152
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3875
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
74164925133N00000X
A3549643171400000X
NCA18676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach