Individual
FREDERICK CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3300 36TH ST SE, GRAND RAPIDS, MI 49512-2810
(616) 831-5660
Mailing address
3300 36TH ST SE, GRAND RAPIDS, MI 49512-2810
(616) 831-5660
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
—
—
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2910854
—
OH
Enumeration date
11/17/2017
Last updated
03/17/2025
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