1063482578 NPI number — MS. MARY JOSEPHINE CLARK M.A., L.P.C.

Table of content: MS. MARY JOSEPHINE CLARK M.A., L.P.C. (NPI 1063482578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063482578 NPI number — MS. MARY JOSEPHINE CLARK M.A., L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MARY
Provider Middle Name:
JOSEPHINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.P.C.
Provider Gender Code:
F

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:
1063482578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1680 44TH ST SE UNIT 8074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49518-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-262-9749
Provider Business Mailing Address Fax Number:
866-416-7581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4835 EASTERN AVE SE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
KENTWOOD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49508-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-262-9749
Provider Business Practice Location Address Fax Number:
866-416-7581
Provider Enumeration Date:
01/25/2006

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: 101YP2500X , with the licence number:  6401005964 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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