Provider Demographics
NPI:1104030899
Name:CLARK, TINA MICHELLE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FERRIER RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4817
Practice Address - Country:US
Practice Address - Phone:360-748-6696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00049995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health