Provider Demographics
NPI:1427696327
Name:CLARK, REBECKA MARIE (RDH, LMT)
Entity type:Individual
Prefix:
First Name:REBECKA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 74TH DRIVE NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-8898
Mailing Address - Country:US
Mailing Address - Phone:253-709-0066
Mailing Address - Fax:
Practice Address - Street 1:5609 74TH DR NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-8898
Practice Address - Country:US
Practice Address - Phone:360-447-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60556285124Q00000X
WAMA61212380225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No124Q00000XDental ProvidersDental Hygienist