Provider Demographics
NPI:1821010190
Name:CLARK, ELIZABETH A (LSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:HESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0168
Mailing Address - Country:US
Mailing Address - Phone:360-683-8998
Mailing Address - Fax:360-457-1439
Practice Address - Street 1:634 E. EIGHTH ST.
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-1446
Practice Address - Country:US
Practice Address - Phone:360-683-8998
Practice Address - Fax:360-457-1439
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000089391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8862104Medicare ID - Type Unspecified
WA1821010190Medicare UPIN