Provider Demographics
NPI:1750921417
Name:CLARK, KEISA LAVETTE
Entity type:Individual
Prefix:
First Name:KEISA
Middle Name:LAVETTE
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 1:3119 BRADFORD CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48380-2034
Mailing Address - Country:US
Mailing Address - Phone:313-647-1201
Mailing Address - Fax:
Practice Address - Street 1:3119 BRADFORD CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48380-2034
Practice Address - Country:US
Practice Address - Phone:313-647-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician