Healthcare Provider Details

I. General information

NPI: 1740647718
Provider Name (Legal Business Name): CLIFFORD TIMOTHY BARRY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 GOGUAC ST W STE B2
SPRINGFIELD MI
49015-2097
US

IV. Provider business mailing address

8653 N 32ND ST STE 1A
RICHLAND MI
49083-9494
US

V. Phone/Fax

Practice location:
  • Phone: 269-223-7786
  • Fax:
Mailing address:
  • Phone: 269-967-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401001261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: