Provider Demographics
NPI:1871531400
Name:CLARK&ASSOCIATES PSYCHOLOGICAL SERVICES, P.C.
Entity type:Organization
Organization Name:CLARK&ASSOCIATES PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:AURELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-559-2673
Mailing Address - Street 1:16250 NORTHLAND DR, SUITE 245
Mailing Address - Street 2:16250 NORTHLAND DRIVE, SUITE 245
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5227
Mailing Address - Country:US
Mailing Address - Phone:248-559-2673
Mailing Address - Fax:248-559-7944
Practice Address - Street 1:16250 NORTHLAND DR, SUITE 245
Practice Address - Street 2:16250 NORTHLAND DRIVE, SUITE 245
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5227
Practice Address - Country:US
Practice Address - Phone:248-559-2673
Practice Address - Fax:248-559-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001882261QM0801X
MI261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP37560Medicare PIN