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General NPI Number Information
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NPI Number | 1447076195
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Entity Type | Individual
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Provider Name | MADELINE CLARK
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Gender | Female
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Dates
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Enumeration Date | 11/26/2024
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 2150 S AIRPORT RD W
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-4705
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Country | US
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Telephone | 231-571-0445
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Fax |
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Provider Business Mailing Address
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Address Line | 105 HENRY ST APT 5
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City | ELK RAPIDS
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State | MI
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Zip | 49629-9791
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Country | US
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Telephone | 231-709-2541
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6851119055
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License Number State | MI
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