Provider Demographics
NPI:1144575812
Name:CLARK, TANYA DELORISE
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:DELORISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 CASS AVE APT 1006
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3683
Mailing Address - Country:US
Mailing Address - Phone:813-447-1935
Mailing Address - Fax:
Practice Address - Street 1:30301 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3277
Practice Address - Country:US
Practice Address - Phone:248-837-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451018990101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor