Provider Demographics
NPI:1811001126
Name:CLARK, MATTHEW DAVID AYERS (PSYD, FLP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID AYERS
Last Name:CLARK
Suffix:
Gender:M
Credentials:PSYD, FLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 KALAMAZOO AVE SE
Mailing Address - Street 2:STE C
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9126
Mailing Address - Country:US
Mailing Address - Phone:616-690-5437
Mailing Address - Fax:616-825-6225
Practice Address - Street 1:7150 KALAMAZOO AVE SE
Practice Address - Street 2:STE C
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9126
Practice Address - Country:US
Practice Address - Phone:616-690-5437
Practice Address - Fax:616-825-6225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013305103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16189090OtherMEDICARE
MI0897749OtherBLUE CROSS BLUE SHIELD