Provider Demographics
NPI:1477947190
Name:CLARK, CARY ANN
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:ANN
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 1:2218 JACKSON AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4535
Mailing Address - Country:US
Mailing Address - Phone:270-305-9625
Mailing Address - Fax:
Practice Address - Street 1:2218 JACKSON AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4535
Practice Address - Country:US
Practice Address - Phone:270-305-9625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60303688101YM0800X
103K00000X, 104100000X
WASA603033851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical