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General NPI Number Information
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NPI Number | 1497907190
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Entity Type | Individual
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Provider Name | BRIAN R. CLARK L.P.C.
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Gender | Male
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Dates
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Enumeration Date | 10/14/2008
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 623 W EASTERDAY AVE
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City | SAULT SAINTE MARIE
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State | MI
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Zip | 49783-1625
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Country | US
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Telephone | 906-635-2752
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Fax |
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Provider Business Mailing Address
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Address Line | 2684 KAVANAUGH ST
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City | OSSINEKE
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State | MI
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Zip | 49766-9784
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Country | US
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Telephone | 989-471-2205
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401000919
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801016728
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License Number State | MI
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