Provider Demographics
NPI:1316815145
Name:CLARK, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:20557 MOTOR DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1887
Mailing Address - Country:US
Mailing Address - Phone:248-383-3816
Mailing Address - Fax:
Practice Address - Street 1:20557 MOTOR DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1887
Practice Address - Country:US
Practice Address - Phone:248-383-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist