Provider Demographics
NPI:1700503331
Name:CLARK, RACHEL GRACE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:GRACE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30527 BURBANK ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2925
Mailing Address - Country:US
Mailing Address - Phone:734-502-4178
Mailing Address - Fax:
Practice Address - Street 1:133 W MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1548
Practice Address - Country:US
Practice Address - Phone:248-347-1168
Practice Address - Fax:248-347-1252
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006226208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation