Provider Demographics
NPI:1184804262
Name:CLARK, SUZANNE MARIE (LMP)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:141 FIELDS RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8506
Mailing Address - Country:US
Mailing Address - Phone:509-899-2819
Mailing Address - Fax:
Practice Address - Street 1:11314 4TH AVE W
Practice Address - Street 2:STE 103
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-6926
Practice Address - Country:US
Practice Address - Phone:425-355-3739
Practice Address - Fax:425-514-8353
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist