Basic Information
Provider Information | |||||||||
NPI: | 1528198389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR CHT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 805 MADISON ST | ||||||||
Address2: | SUITE 901 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981041172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062648100 | ||||||||
FaxNumber: | 2062648689 | ||||||||
Practice Location | |||||||||
Address1: | 12911 120TH AVE NE | ||||||||
Address2: | SUITE H 220 | ||||||||
City: | KIRKLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 980343027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252167075 | ||||||||
FaxNumber: | 4252167094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 10/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT00001716 | WA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225XH1200X | 9711000164 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
ID | Type | State | Issuer | Description | 7466CL | 01 | WA | REGENCE | OTHER | 126095 | 01 | WA | L & I | OTHER | 7680697 | 05 | WA |   | MEDICAID |