Provider Demographics
NPI:1700523370
Name:CLARK, TONI MARIE
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:MARIE
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:PO BOX 4103
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49016-4103
Mailing Address - Country:US
Mailing Address - Phone:269-967-5328
Mailing Address - Fax:260-963-6567
Practice Address - Street 1:191 WAUBASCON RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-2146
Practice Address - Country:US
Practice Address - Phone:269-967-5328
Practice Address - Fax:269-963-6567
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI246Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health