Provider Demographics
NPI:1154548147
Name:CLARK, NANCY RUTH
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:RUTH
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 N VIEWMONT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2659
Mailing Address - Country:US
Mailing Address - Phone:360-428-0423
Mailing Address - Fax:
Practice Address - Street 1:4308 76TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3720
Practice Address - Country:US
Practice Address - Phone:425-349-6860
Practice Address - Fax:425-349-7366
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA020701 RC00015401101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health