Provider Demographics
NPI:1073611448
Name:CLARK, DAVID (LMSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:WESLEY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:980 KEATON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-1861
Mailing Address - Country:US
Mailing Address - Phone:248-879-1277
Mailing Address - Fax:248-250-6919
Practice Address - Street 1:980 KEATON DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-1861
Practice Address - Country:US
Practice Address - Phone:248-879-1277
Practice Address - Fax:248-250-6919
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68010027381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker