Provider Demographics
NPI:1780373977
Name:CLARK, SHAWN ANDREW
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ANDREW
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 W LEONARD RD
Mailing Address - Street 2:
Mailing Address - City:MANCELONA
Mailing Address - State:MI
Mailing Address - Zip Code:49659-9794
Mailing Address - Country:US
Mailing Address - Phone:231-468-8138
Mailing Address - Fax:
Practice Address - Street 1:945 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4250
Practice Address - Country:US
Practice Address - Phone:231-268-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician