Provider Demographics
NPI:1144890658
Name:CLARK, KATHARINE (MA60389081)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA60389081
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:
Other - Last Name:MCCLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8927 W TUCANNON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7176
Mailing Address - Country:US
Mailing Address - Phone:206-331-8509
Mailing Address - Fax:
Practice Address - Street 1:8927 W TUCANNON AVE STE 102
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7176
Practice Address - Country:US
Practice Address - Phone:206-331-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60389081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist