Active NPI
Tina Michelle Clark
- Mental Health Counselor
- Chehalis, WA
National Provider Identifier
1104030899
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- RC00049995
- Practice address
- 135 W Main St
Chehalis, WA 98532-4817 - Phone
- (360) 748-6696
- NPI assigned
- May 10, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | RC00049995 | WA | Primary |
Addresses
Primary practice location
135 W Main St
Chehalis, WA 98532-4817
Mailing address
1313 Ferrier Rd
Winlock, WA 98596-9330
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RC00049995 | WA | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1178755200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1104030899",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1313 FERRIER RD",
"city": "WINLOCK",
"state": "WA",
"postal_code": "985969330"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "135 W MAIN ST",
"city": "CHEHALIS",
"state": "WA",
"postal_code": "985324817",
"telephone_number": "360-748-6696"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "TINA",
"middle_name": "MICHELLE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-05-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "WA",
"license": "RC00049995",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chehalis, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.