Provider Demographics
NPI:1831219971
Name:AQUINO-MASCORRO, CLARA M (DM, CAC-II,LBSW)
Entity type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:M
Last Name:AQUINO-MASCORRO
Suffix:
Gender:F
Credentials:DM, CAC-II,LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 OLD ALLEGAN RD
Mailing Address - Street 2:
Mailing Address - City:FENNVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49408-9495
Mailing Address - Country:US
Mailing Address - Phone:269-561-4845
Mailing Address - Fax:
Practice Address - Street 1:412 CENTURY LN
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4285
Practice Address - Country:US
Practice Address - Phone:616-396-2301
Practice Address - Fax:616-396-8070
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-00839101YA0400X
MI6802079603104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker