Provider Demographics
NPI:1598934390
Name:CLARK, ELIZABETH (LMP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
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 1:85310 N HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-9260
Mailing Address - Country:US
Mailing Address - Phone:509-921-2688
Mailing Address - Fax:509-967-9400
Practice Address - Street 1:4096 W VAN GIESEN ST STE E
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-5021
Practice Address - Country:US
Practice Address - Phone:509-967-9400
Practice Address - Fax:509-967-9400
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024200172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist