Provider Demographics
NPI:1679610927
Name:CLARK, LINDA PATRICIA (LMP)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:PATRICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1284
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-1284
Mailing Address - Country:US
Mailing Address - Phone:253-307-7227
Mailing Address - Fax:360-897-6163
Practice Address - Street 1:14610 229TH AVE E
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-9669
Practice Address - Country:US
Practice Address - Phone:253-307-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA66473OtherL&I NUMBER
WA7694CLOtherREGENCE RIDER NUMBER
WA66473OtherL&I NUMBER