Provider Demographics
NPI:1699499400
Name:CLARK, MICHELE R (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 TWINGATE DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6312
Mailing Address - Country:US
Mailing Address - Phone:404-406-2844
Mailing Address - Fax:
Practice Address - Street 1:10200 TWINGATE DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-6312
Practice Address - Country:US
Practice Address - Phone:404-406-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001977106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist