Provider Demographics
NPI:1497213946
Name:CLARK, SHEILA A (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 YORKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2140
Mailing Address - Country:US
Mailing Address - Phone:313-485-0930
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD STE 106
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4503
Practice Address - Country:US
Practice Address - Phone:248-676-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015688101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401015688Medicaid