Provider Demographics
NPI:1821159690
Name:CLARK, KIRSTEN (PT)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 MARTIN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-4135
Mailing Address - Country:US
Mailing Address - Phone:248-366-9170
Mailing Address - Fax:248-366-9176
Practice Address - Street 1:20031 CARLYSLE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3803
Practice Address - Country:US
Practice Address - Phone:313-277-9170
Practice Address - Fax:313-277-9176
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004619174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN84780003Medicare ID - Type Unspecified