Provider Demographics
NPI:1114040979
Name:CLARK, CASSANDRA ANN (BA)
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 502
Mailing Address - Street 2:815 SE TRINITY
Mailing Address - City:WILBUR
Mailing Address - State:WA
Mailing Address - Zip Code:99185-0502
Mailing Address - Country:US
Mailing Address - Phone:509-647-5730
Mailing Address - Fax:509-725-4901
Practice Address - Street 1:49 PARK STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122-0421
Practice Address - Country:US
Practice Address - Phone:509-725-4900
Practice Address - Fax:509-725-4901
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00023755101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health