MEDICARE: MADELINE CLARK LLMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6851119055	MI

General Provider Information

NPI Number	:	1447076195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE CLARK LLMSW

Provider Business Mailing Address
First Line	:	5024 N ROYAL DR STE B
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-9230
Country	:	US
Telephone Number	:	231-276-1999
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 S AIRPORT RD W
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4705
Country	:	US
Telephone Number	:	231-571-0445
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2024
Last Update Date	:	05/18/2026

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