Provider Demographics
NPI:1073158317
Name:CLARK, MELBA LYNETTE (MA LPC NCC)
Entity Type:Individual
Prefix:MRS
First Name:MELBA
Middle Name:LYNETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 ANTIETAM AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2832
Mailing Address - Country:US
Mailing Address - Phone:231-343-0630
Mailing Address - Fax:
Practice Address - Street 1:1010 ANTIETAM AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2832
Practice Address - Country:US
Practice Address - Phone:313-303-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017626101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional