Provider Demographics
NPI:1902124761
Name:CLARK, KAREN (MA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W WACKERLY ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2769
Mailing Address - Country:US
Mailing Address - Phone:989-832-2165
Mailing Address - Fax:989-839-4376
Practice Address - Street 1:720 W WACKERLY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2769
Practice Address - Country:US
Practice Address - Phone:989-832-2165
Practice Address - Fax:989-839-4376
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007795103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist