Provider Demographics
NPI:1659453397
Name:CLARK, CHERELYN (MA, MSED)
Entity Type:Individual
Prefix:MS
First Name:CHERELYN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, MSED
Other - Prefix:
Other - First Name:CHERE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:6212 75TH ST W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8368
Mailing Address - Country:US
Mailing Address - Phone:253-208-1204
Mailing Address - Fax:253-584-2710
Practice Address - Street 1:6212 75TH ST W
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8368
Practice Address - Country:US
Practice Address - Phone:253-208-1204
Practice Address - Fax:253-584-2710
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011319101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health