Provider Demographics
NPI:1558090969
Name:KRISTIE CLARK, PLLC
Entity Type:Organization
Organization Name:KRISTIE CLARK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-430-6553
Mailing Address - Street 1:12375 WHISPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-9500
Mailing Address - Country:US
Mailing Address - Phone:989-430-6553
Mailing Address - Fax:989-355-0438
Practice Address - Street 1:5090 STATE ST STE B102
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3778
Practice Address - Country:US
Practice Address - Phone:989-430-6553
Practice Address - Fax:989-355-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-09
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health