Provider Demographics
NPI:1346633187
Name:CLARK, THELMA STALEY (CRC, LPC)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:STALEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRC, LPC
Other - Prefix:DR
Other - First Name:THELMA
Other - Middle Name:STALEY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRC, LPC
Mailing Address - Street 1:9329 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1260
Mailing Address - Country:US
Mailing Address - Phone:313-450-4500
Mailing Address - Fax:313-450-4514
Practice Address - Street 1:9329 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:313-450-4514
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00049452101YP2500X
MI6401008178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional