Provider Demographics
NPI:1275003873
Name:CLARK, ANGELA (MSW,LICSWA, MCA,SUDP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW,LICSWA, MCA,SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:
Practice Address - Street 1:317 N. PINES
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99206
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:509-326-5025
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60656762101YA0400X
WAMC61249881101Y00000X
WASC60656780104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor