Provider Demographics
NPI:1861053811
Name:CLARK, THOMAS J (LMT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16615 NORTH RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5983
Mailing Address - Country:US
Mailing Address - Phone:206-498-4681
Mailing Address - Fax:
Practice Address - Street 1:16615 NORTH RD UNIT B
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-5983
Practice Address - Country:US
Practice Address - Phone:206-498-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60546680225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty