Provider Demographics
NPI:1457301400
Name:CLARK, TARA W (SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:K
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE
Mailing Address - Street 2:BOX 359735
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-341-4612
Mailing Address - Fax:206-341-4614
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX 359735
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-341-4612
Practice Address - Fax:206-341-4614
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004111235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA54344UOtherREGENCE BLUE SHIELD PIN