Basic Information
| Provider Information | |||||||||
| NPI: | 1619458999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 S. COLUMBIAN WAY | ||||||||
| Address2: | MAILSTOP: (S-116) | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067642007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1660 S. COLUMBIAN WAY | ||||||||
| Address2: | MAILSTOP: (S-116) | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067642007 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2018 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 61139465 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.