MEDICARE: MICHELLE CLARK LPC, CAC II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1538229455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE CLARK LPC, CAC II

Provider Business Mailing Address
First Line	:	509 HANNA ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-1721
Country	:	US
Telephone Number	:	970-231-1275
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 HANNA ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-1721
Country	:	US
Telephone Number	:	970-231-1275
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	11/09/2011

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