| Doctor Name: | DYNETTA CLARK |
| NPI Number: | 1003125261 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA, LLP |
| License Number: | 6301012368 |
| Business Practice Address: | 805 Leonard St Ne Grand Rapids, MI - 495031138 |
| Business Phone Number: | 6164512021 |
| Business Fax Number: | 6167741001 |
| Mailing Address: | 1751 Kendall St Se, GRAND RAPIDS |
| State: | MI |
| Postal Code: | 495083746 |
| Phone Number: | 6164512021 |
| Fax Number: | 6167741001 |
| NPI Enumeration Date: | 10/05/2010 |
| NPI Last Update Date: | 10/05/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6301012368 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |