Provider Demographics
NPI:1508917055
Name:CLARK, EMMA JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 140TH AVE. NE
Mailing Address - Street 2:SUITE B-105
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005
Mailing Address - Country:US
Mailing Address - Phone:425-644-6328
Mailing Address - Fax:425-644-6295
Practice Address - Street 1:21907 64TH AVE. W
Practice Address - Street 2:SUITE # 110
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043
Practice Address - Country:US
Practice Address - Phone:425-673-5220
Practice Address - Fax:425-673-1597
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00028464225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist