Provider Demographics
NPI:1164210688
Name:CLARK, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELSA
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:42 ELOCHOMAN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-9602
Mailing Address - Country:US
Mailing Address - Phone:360-795-8630
Mailing Address - Fax:
Practice Address - Street 1:42 ELOCHOMAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9602
Practice Address - Country:US
Practice Address - Phone:360-795-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor