Provider Demographics
NPI:1326326729
Name:CLARK, MICHELE J (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1305 ALMOND CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-5623
Mailing Address - Country:US
Mailing Address - Phone:757-214-8758
Mailing Address - Fax:
Practice Address - Street 1:289 INDEPENDENCE BLVD
Practice Address - Street 2:STE 245
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5493
Practice Address - Country:US
Practice Address - Phone:757-385-0850
Practice Address - Fax:757-518-9713
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0701003827101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid