Provider Demographics
NPI:1750684627
Name:CLARK, ELAINE FRANCES (LMP)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:FRANCES
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MISS
Other - First Name:ELAINE
Other - Middle Name:FRANCES
Other - Last Name:FROELICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:9730 STATE ROUTE 532 STE D
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-8054
Mailing Address - Country:US
Mailing Address - Phone:360-572-3709
Mailing Address - Fax:360-572-4481
Practice Address - Street 1:9730 STATE ROUTE 532 STE D
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8054
Practice Address - Country:US
Practice Address - Phone:360-572-3709
Practice Address - Fax:360-572-3709
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00024125174400000X
WAMA00024125225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist