Basic Information
| Provider Information | |||||||||
| NPI: | 1104301316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MELODY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 FRONT ST S STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984999415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535843996 | ||||||||
| FaxNumber: | 2533891071 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 FRONT ST S STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984999415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535843996 | ||||||||
| FaxNumber: | 2535891071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60644204 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.