Provider Demographics
NPI:1306171152
Name:CLARK, MARSHA J (MA, LLCP)
Entity type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LLCP
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 616
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-0616
Mailing Address - Country:US
Mailing Address - Phone:517-242-7190
Mailing Address - Fax:
Practice Address - Street 1:7804 FRANCIS CT
Practice Address - Street 2:220
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7769
Practice Address - Country:US
Practice Address - Phone:517-242-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011466101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor