Provider Demographics
NPI:1083295414
Name:CLARK, ANDREW LEON
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:LEON
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8336 MONROE RD RM 120
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9340
Mailing Address - Country:US
Mailing Address - Phone:734-807-0162
Mailing Address - Fax:
Practice Address - Street 1:8336 MONROE RD RM 120
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9340
Practice Address - Country:US
Practice Address - Phone:734-807-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional