Provider Demographics
NPI:1649711615
Name:CLARK, CLIFFORD JOVAN (LLMSW)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:JOVAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44070 W 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2648
Mailing Address - Country:US
Mailing Address - Phone:248-773-8440
Mailing Address - Fax:248-773-8441
Practice Address - Street 1:44070 W 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2648
Practice Address - Country:US
Practice Address - Phone:248-773-8440
Practice Address - Fax:248-773-8441
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801100714101YM0800X, 101YP1600X, 101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical