Provider Demographics
NPI:1205193984
Name:CLARK, KELSEY NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:N
Other - Last Name:USHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:112 W 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-1719
Mailing Address - Country:US
Mailing Address - Phone:509-566-2061
Mailing Address - Fax:
Practice Address - Street 1:4407 N DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1660
Practice Address - Country:US
Practice Address - Phone:509-566-2061
Practice Address - Fax:509-566-2061
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60243441101YA0400X
WAMG60679997106H00000X, 106H00000X
WALF60878729106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALF60878729OtherSTATE LICENSING BOARD
WALF60878729OtherSTATE LICENSING BOARD