Provider Demographics
NPI:1114593373
Name:CLARK, LISA JANE (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10430W COUNTY ROAD 442
Mailing Address - Street 2:
Mailing Address - City:COOKS
Mailing Address - State:MI
Mailing Address - Zip Code:49817-9770
Mailing Address - Country:US
Mailing Address - Phone:906-286-2943
Mailing Address - Fax:
Practice Address - Street 1:10430W COUNTY ROAD 442
Practice Address - Street 2:
Practice Address - City:COOKS
Practice Address - State:MI
Practice Address - Zip Code:49817-9770
Practice Address - Country:US
Practice Address - Phone:906-286-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health