Provider Demographics
NPI:1043688583
Name:CLARK, CHARLES MICHAEL II (LMHC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:CLARK
Suffix:II
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 PACIFIC ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4244
Mailing Address - Country:US
Mailing Address - Phone:253-201-6070
Mailing Address - Fax:
Practice Address - Street 1:6314 19TH ST W STE 7
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6223
Practice Address - Country:US
Practice Address - Phone:253-201-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health