Healthcare Provider Details

I. General information

NPI: 1609459171
Provider Name (Legal Business Name): MIKAELA MICHELE CLARKE MS, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIKAELA MICHELE SERGENT MS, BCBA, LBA

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 PINE ST
PORT HURON MI
48060-5400
US

IV. Provider business mailing address

1615 WHITE ST
PORT HURON MI
48060-5639
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-9991
  • Fax:
Mailing address:
  • Phone: 810-937-7048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002674
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: