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Individual
JUSTIN CLARK
Active
Individual
JUSTIN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BA HISTORY
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8300012
—
NC
Enumeration date
04/11/2013
Last updated
04/11/2013
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