Provider Demographics
NPI:1497298046
Name:CLARK L.M.P., CATHY A (LIC MASSAGE PRACTIT)
Entity Type:Individual
Prefix:MS
First Name:CATHY
Middle Name:A
Last Name:CLARK L.M.P.
Suffix:
Gender:F
Credentials:LIC MASSAGE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186-375 HWY. 101
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331
Mailing Address - Country:US
Mailing Address - Phone:360-374-5395
Mailing Address - Fax:
Practice Address - Street 1:186-375 HWY. 101
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331
Practice Address - Country:US
Practice Address - Phone:360-374-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist