Provider Demographics
NPI:1093009458
Name:CLARK, ROBERT LEE (MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:905 NE 68TH ST
Mailing Address - Street 2:STE 2
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-0585
Mailing Address - Country:US
Mailing Address - Phone:360-991-8759
Mailing Address - Fax:360-574-2806
Practice Address - Street 1:905 NE 68TH ST
Practice Address - Street 2:STE 2
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0585
Practice Address - Country:US
Practice Address - Phone:360-991-8759
Practice Address - Fax:360-574-2806
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007258101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor