Provider Demographics
NPI:1154614808
Name:CLARK, HEIDI C
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:C
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:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:SUQUAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98392-0065
Mailing Address - Country:US
Mailing Address - Phone:360-265-0270
Mailing Address - Fax:
Practice Address - Street 1:31912 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9700
Practice Address - Country:US
Practice Address - Phone:360-633-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005554171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator