Provider Demographics
NPI:1528257433
Name:S L CLARK MD INC PS
Entity type:Organization
Organization Name:S L CLARK MD INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-355-2800
Mailing Address - Street 1:9515 60TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275
Mailing Address - Country:US
Mailing Address - Phone:425-355-2800
Mailing Address - Fax:425-355-2882
Practice Address - Street 1:9515 60TH AVE W
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275
Practice Address - Country:US
Practice Address - Phone:425-355-2800
Practice Address - Fax:425-355-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022790103TP0016X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB17499Medicare UPIN
WAAB17499Medicare UPIN