MEDICARE: EMILY ELIZABETH CLARK

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	104100000X	Social Worker	6801110288	MI
2	1041C0700X	Clinical Social Worker	6801110288	MI

General Provider Information

NPI Number	:	1881263846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY ELIZABETH CLARK

Provider Business Mailing Address
First Line	:	2360 LANCASHIRE DR APT 2B
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-1334
Country	:	US
Telephone Number	:	734-752-1338
Fax Number	:

Provider Business Practice Location Address
First Line	:	147 N MILFORD RD STE 201
Second Line	:
City	:	HIGHLAND
State	:	MI
Zip	:	48357-4500
Country	:	US
Telephone Number	:	248-563-0587
Fax Number	:

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

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	07/24/2021

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Directions to “ EMILY ELIZABETH CLARK ” Practice Location

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