Provider Demographics
NPI:1972813517
Name:CLARK, MICHELLE ANN (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10904 57TH ST NE STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4654
Mailing Address - Country:US
Mailing Address - Phone:763-497-0733
Mailing Address - Fax:763-497-0728
Practice Address - Street 1:10904 57TH ST NE STE 106
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4654
Practice Address - Country:US
Practice Address - Phone:763-497-0733
Practice Address - Fax:763-497-0728
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2110106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972813517Medicaid