Provider Demographics
NPI:1265575674
Name:CLARK, MICHELLE THERESA (LMHC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 872
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02768-0872
Mailing Address - Country:US
Mailing Address - Phone:508-208-7561
Mailing Address - Fax:
Practice Address - Street 1:10 COMMERCE WAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1071
Practice Address - Country:US
Practice Address - Phone:508-208-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC 910101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health