Provider Demographics
NPI:1770620064
Name:CLARK THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:CLARK THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:253-847-2687
Mailing Address - Street 1:PO BOX 988
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-0988
Mailing Address - Country:US
Mailing Address - Phone:253-847-2687
Mailing Address - Fax:253-846-3012
Practice Address - Street 1:10107 213TH ST E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8059
Practice Address - Country:US
Practice Address - Phone:253-847-2687
Practice Address - Fax:253-846-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA66473OtherL&I NUMBER
WA7694CLOtherREGENCE PROVIDER NUMBER