Provider Demographics
NPI:1568078947
Name:CLARK, MICHELLE JEAN (LAPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SADDLEBRUSH RD
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-7402
Mailing Address - Country:US
Mailing Address - Phone:719-337-6592
Mailing Address - Fax:
Practice Address - Street 1:318 S WELBORN ST STE C
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3127
Practice Address - Country:US
Practice Address - Phone:912-332-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional