Provider Demographics
NPI:1851445670
Name:CLARK, NICOLE ANN (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4607
Mailing Address - Country:US
Mailing Address - Phone:734-478-5151
Mailing Address - Fax:
Practice Address - Street 1:2051 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4607
Practice Address - Country:US
Practice Address - Phone:734-478-5151
Practice Address - Fax:734-994-8284
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010634791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N61370002Medicare ID - Type UnspecifiedMEDICARE