Provider Demographics
NPI:1164892873
Name:CLARK, JULIE KATHLEEN (MS, LPC, CRC, MITS)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:KATHLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LPC, CRC, MITS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BAY STREET
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-622-5061
Mailing Address - Fax:
Practice Address - Street 1:220 BAY ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2473
Practice Address - Country:US
Practice Address - Phone:231-622-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional