Provider Demographics
NPI:1801113063
Name:CLEGG, DAVID WILLIAM (LICENSED COUNSELOR)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:CLEGG
Suffix:
Gender:M
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 ROGERS ST NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4211
Mailing Address - Country:US
Mailing Address - Phone:360-943-6642
Mailing Address - Fax:
Practice Address - Street 1:1412 ROGERS ST NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4211
Practice Address - Country:US
Practice Address - Phone:360-943-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60124983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health