Provider Demographics
NPI:1568674943
Name:CLARK, TORI RABY (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:TORI
Middle Name:RABY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:MS
Other - First Name:TORI
Other - Middle Name:
Other - Last Name:RABY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MT-BC
Mailing Address - Street 1:1303 N CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4605
Mailing Address - Country:US
Mailing Address - Phone:734-649-6599
Mailing Address - Fax:
Practice Address - Street 1:1303 N CONGRESS ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-4605
Practice Address - Country:US
Practice Address - Phone:734-649-6599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC462799730061225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist