Provider Demographics
NPI:1053615989
Name:CLARK, DEIRDRE V (DC, ND, CHT, CCRA)
Entity type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:V
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC, ND, CHT, CCRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10926 DAVID TAYLOR DR STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0039
Mailing Address - Country:US
Mailing Address - Phone:704-266-3250
Mailing Address - Fax:
Practice Address - Street 1:10926 DAVID TAYLOR DR STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1042
Practice Address - Country:US
Practice Address - Phone:704-266-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5172111NI0013X, 111N00000X
NC5171111NI0013X
171M00000X, 1744R1102X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1744R1102XOther Service ProvidersSpecialistResearch Study
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5172OtherCHIROPRACTIC LICENSE