Provider Demographics
NPI:1114455979
Name:CLARK, LAUREL MEGAN (LMT)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:MEGAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 SE 165TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4324
Mailing Address - Country:US
Mailing Address - Phone:360-823-2225
Mailing Address - Fax:360-823-2227
Practice Address - Street 1:2415 SE 165TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4324
Practice Address - Country:US
Practice Address - Phone:360-823-2225
Practice Address - Fax:360-823-2227
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60756541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60756541OtherMASSAGE LICENSE
WA1409013OtherAMTA MEMBERSHIP