Provider Demographics
NPI:1811582414
Name:CLARKE, DIANA ROSE
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ROSE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YOUTH CAMP LN APT 206D
Mailing Address - Street 2:
Mailing Address - City:NASELLE
Mailing Address - State:WA
Mailing Address - Zip Code:98638-8602
Mailing Address - Country:US
Mailing Address - Phone:186-325-7209
Mailing Address - Fax:
Practice Address - Street 1:2204 PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3300
Practice Address - Country:US
Practice Address - Phone:360-227-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health