Provider Demographics
NPI:1376853762
Name:CLARK, TARA LYNN (LMHC, LSWAIC, MSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC, LSWAIC, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 N WENATCHEE AVE STE H
Mailing Address - Street 2:#330
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1599
Mailing Address - Country:US
Mailing Address - Phone:509-334-7123
Mailing Address - Fax:
Practice Address - Street 1:3539 DIANNA WAY
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-9142
Practice Address - Country:US
Practice Address - Phone:509-334-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC608633651041C0700X
WALH61072662101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2102809Medicaid