Provider Demographics
NPI:1821864802
Name:CLARK, ALEXSAUNDRA TONI
Entity Type:Individual
Prefix:
First Name:ALEXSAUNDRA
Middle Name:TONI
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S RAISINVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9754
Mailing Address - Country:US
Mailing Address - Phone:734-384-0458
Mailing Address - Fax:
Practice Address - Street 1:1001 S RAISINVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9754
Practice Address - Country:US
Practice Address - Phone:734-384-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health