Provider Demographics
NPI:1063482578
Name:CLARK, MARY JOSEPHINE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOSEPHINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1680 44TH ST SE UNIT 8074
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49518-5005
Mailing Address - Country:US
Mailing Address - Phone:616-262-9749
Mailing Address - Fax:866-416-7581
Practice Address - Street 1:4835 EASTERN AVE SE
Practice Address - Street 2:SUITE 102
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4729
Practice Address - Country:US
Practice Address - Phone:616-262-9749
Practice Address - Fax:866-416-7581
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005964101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional