Basic Information
| Provider Information | |||||||||
| NPI: | 1508917055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2445 140TH AVE. NE | ||||||||
| Address2: | SUITE B-105 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256446328 | ||||||||
| FaxNumber: | 4256446295 | ||||||||
| Practice Location | |||||||||
| Address1: | 21907 64TH AVE. W | ||||||||
| Address2: | SUITE # 110 | ||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256735220 | ||||||||
| FaxNumber: | 4256731597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00028464 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.