Provider Demographics
NPI:1598892085
Name:CLARK, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9515 60TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275
Mailing Address - Country:US
Mailing Address - Phone:425-355-2800
Mailing Address - Fax:425-355-2882
Practice Address - Street 1:9515 60TH AVE W
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275
Practice Address - Country:US
Practice Address - Phone:425-355-2800
Practice Address - Fax:425-355-2882
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025209MD000227902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
91202381600OtherUNIFORM
148493100000OtherPREMERA
9120238161816CLOtherREGENCE
WA822269436OtherUNITED BEHAVIORAL HEALTH
WA177558OtherVALUEOPTIONS
WA1117944Medicaid
381601OtherPACIFICARE
WA389227520070221OtherCOMMUNITY HEALTH PLAN
WA389227520070221OtherCOMMUNITY HEALTH PLAN
F75788Medicare UPIN
WAAB17499Medicare ID - Type Unspecified