Provider Demographics
NPI:1982072765
Name:CLARK, GILBERT
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:
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 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-876-6527
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:520 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2588
Practice Address - Country:US
Practice Address - Phone:231-775-6521
Practice Address - Fax:231-775-1366
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01085101YA0400X
MN303944101YA0400X
MN02015101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)