Provider Demographics
NPI:1538720099
Name:CLARK, TYRIC ALLEN (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:TYRIC
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 SANDRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626-9601
Mailing Address - Country:US
Mailing Address - Phone:989-798-4784
Mailing Address - Fax:
Practice Address - Street 1:3949 N RIVER RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-8856
Practice Address - Country:US
Practice Address - Phone:989-702-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC462809051450106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician