Provider Demographics
NPI:1689190290
Name:CLARK, FANCHON MARIE (MA, LPC, CAADC)
Entity type:Individual
Prefix:
First Name:FANCHON
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC, CAADC
Other - Prefix:
Other - First Name:FANCHON
Other - Middle Name:CLARK
Other - Last Name:HARVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 GRIGGS ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2644
Mailing Address - Country:US
Mailing Address - Phone:616-901-1650
Mailing Address - Fax:
Practice Address - Street 1:622 GRIGGS ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-2644
Practice Address - Country:US
Practice Address - Phone:616-901-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional