1104845379 NPI number — MR. CLARK C. CORWIN LCSW

Table of content: MR. CLARK C. CORWIN LCSW (NPI 1104845379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104845379 NPI number — MR. CLARK C. CORWIN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORWIN
Provider First Name:
CLARK
Provider Middle Name:
C.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104845379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 123
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULLOWHEE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28723-0123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4208 SIX FORKS RD
Provider Second Line Business Practice Location Address:
BLDG 1, SUITE 305 A
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-5735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-632-6074
Provider Business Practice Location Address Fax Number:
866-341-7512
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C003338 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6003459 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135P9 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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