Basic Information
| Provider Information | |||||||||
| NPI: | 1265678668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15489 BONNEY LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982738717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604249443 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604193500 | ||||||||
| FaxNumber: | 3604193505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2009 | ||||||||
| LastUpdateDate: | 01/06/2009 | ||||||||
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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 | 101YM0800X | RC60070025 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.