Basic Information
Provider Information | |||||||||
NPI: | 1740755636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLOUGH | ||||||||
FirstName: | ERIKA | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RD, CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3401 S 19TH ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984051909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535731600 | ||||||||
FaxNumber: | 2535731601 | ||||||||
Practice Location | |||||||||
Address1: | 3401 S 19TH ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984051909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535731600 | ||||||||
FaxNumber: | 2535731601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2018 | ||||||||
LastUpdateDate: | 10/08/2018 | ||||||||
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 | 133V00000X | 60296535 | WA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 60296535 | 01 | WA | WA STATE DEPARTMENT OF HEALTH | OTHER | 1045258 | 01 |   | COMMISSION ON DIETETIC REGISTRATION | OTHER |