Provider Demographics
NPI:1336468263
Name:CLARK, JOAN GARY (MA, LMHC)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:GARY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:MS
Other - First Name:GIITA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LMHC
Mailing Address - Street 1:1523 FERN ST SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1029
Mailing Address - Country:US
Mailing Address - Phone:802-598-5522
Mailing Address - Fax:
Practice Address - Street 1:100 SE WHITENER RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7747
Practice Address - Country:US
Practice Address - Phone:802-598-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH.60133754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional