Basic Information
| Provider Information | |||||||||
| NPI: | 1437439775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LYNNE | ||||||||
| MiddleName: | MARIAN | ||||||||
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| Credential: | MSW/LICSW/MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094746960 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 8TH AVE STE 660E | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094746960 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2011 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LW60217568 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LW60217568 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SC60159504 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW-35243 | ID | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.