Provider Demographics
NPI:1760500623
Name:CLARK, LINCOLIN HENRY (FAODP)
Entity Type:Individual
Prefix:MR
First Name:LINCOLIN
Middle Name:HENRY
Last Name:CLARK
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 WHITMORE RD APT A1
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1749
Mailing Address - Country:US
Mailing Address - Phone:313-399-3727
Mailing Address - Fax:313-871-0040
Practice Address - Street 1:514 ALGER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2106
Practice Address - Country:US
Practice Address - Phone:313-871-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)