Provider Demographics
NPI:1376928366
Name:CLARK, KRISTIE ANN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5090 STATE ST
Mailing Address - Street 2:SUITE 102-B
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-7706
Mailing Address - Country:US
Mailing Address - Phone:479-685-7830
Mailing Address - Fax:
Practice Address - Street 1:5090 STATE ST
Practice Address - Street 2:SUITE 102-B
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-7706
Practice Address - Country:US
Practice Address - Phone:479-685-7830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011076101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional