Provider Demographics
NPI:1861983116
Name:CLARK, HEATHER NICOLE (MA, MFT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4396
Mailing Address - Country:US
Mailing Address - Phone:843-332-4156
Mailing Address - Fax:843-332-4159
Practice Address - Street 1:510 E CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4396
Practice Address - Country:US
Practice Address - Phone:843-332-4156
Practice Address - Fax:843-332-4159
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA