Provider Demographics
NPI:1164772224
Name:CLARK, MICHELE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 W SUNSET BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6309
Mailing Address - Country:US
Mailing Address - Phone:312-715-7587
Mailing Address - Fax:
Practice Address - Street 1:8629 PEARSON DR
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-1745
Practice Address - Country:US
Practice Address - Phone:312-715-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2022-06-28
Deactivation Date:2018-06-21
Deactivation Code:
Reactivation Date:2022-06-24
Provider Licenses
StateLicense IDTaxonomies
IL149.0147221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical