Provider Demographics
NPI:1083411151
Name:CLARK, MICHELLE (RTT PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:RTT PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 SILVER BEACH DR
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6416
Mailing Address - Country:US
Mailing Address - Phone:385-279-1039
Mailing Address - Fax:
Practice Address - Street 1:596 SILVER BEACH DR
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6416
Practice Address - Country:US
Practice Address - Phone:385-279-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach