Provider Demographics
NPI:1407250079
Name:CLARK, CLAIREMARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLAIREMARIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11335 NE 122ND WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6933
Mailing Address - Country:US
Mailing Address - Phone:425-284-5616
Mailing Address - Fax:425-523-9164
Practice Address - Street 1:11335 NE 122ND WAY STE 105
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6933
Practice Address - Country:US
Practice Address - Phone:425-284-5616
Practice Address - Fax:425-523-9164
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC2200X
WA60717708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077732Medicaid