Provider Demographics
NPI:1558128116
Name:CLARK, VICTORIA DYSHELLE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:DYSHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27550 GROVELAND ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4354
Mailing Address - Country:US
Mailing Address - Phone:586-213-2837
Mailing Address - Fax:
Practice Address - Street 1:27550 GROVELAND ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4354
Practice Address - Country:US
Practice Address - Phone:586-213-2837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511082031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty