Provider Demographics
NPI:1407830359
Name:CLARK, ERICA LYNNE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7228 W MERCER WAY
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-5572
Mailing Address - Country:US
Mailing Address - Phone:206-954-6936
Mailing Address - Fax:206-456-2551
Practice Address - Street 1:9311 SE 36TH ST STE 208
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3741
Practice Address - Country:US
Practice Address - Phone:206-402-6339
Practice Address - Fax:206-456-2551
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7046626Medicaid
WA7046626Medicaid