Provider Demographics
NPI:1528196664
Name:MCCLUNG, BERNALDINE PERKINS (MSW)
Entity Type:Individual
Prefix:
First Name:BERNALDINE
Middle Name:PERKINS
Last Name:MCCLUNG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 KEELSON DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-3073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 BAGLEY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1400
Practice Address - Country:US
Practice Address - Phone:313-965-2141
Practice Address - Fax:313-961-4612
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010816141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOQ26496065Medicare ID - Type Unspecified