Healthcare Provider Details

I. General information

NPI: 1447796321
Provider Name (Legal Business Name): TONYALE FAYE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

IV. Provider business mailing address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401016079
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: