Provider Demographics
NPI:1114455979
Name:CLARK, LAUREL MEGAN (LMT)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:MEGAN
Last Name:CLARK
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2129
Mailing Address - Country:US
Mailing Address - Phone:360-931-0976
Mailing Address - Fax:
Practice Address - Street 1:410 E 20TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3316
Practice Address - Country:US
Practice Address - Phone:360-931-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60756541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1409013OtherAMTA MEMBERSHIP
WAMA60756541OtherMASSAGE LICENSE