Provider Demographics
NPI:1609017987
Name:CLARK, ROBERTA CATHERINE (LS/SW/QMRP)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:CATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LS/SW/QMRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 BELLARMINE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1207
Mailing Address - Country:US
Mailing Address - Phone:248-894-7185
Mailing Address - Fax:
Practice Address - Street 1:1270 DORIS RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2617
Practice Address - Country:US
Practice Address - Phone:248-276-8044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802035968104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker