Provider Demographics
NPI:1376987370
Name:CLARK, MELLISA A
Entity Type:Individual
Prefix:MS
First Name:MELLISA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1832
Mailing Address - Country:US
Mailing Address - Phone:253-495-9707
Mailing Address - Fax:
Practice Address - Street 1:1019 PACIFIC AVE STE 1022
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4491
Practice Address - Country:US
Practice Address - Phone:253-495-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-20
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60309925101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor