| Doctor Name: | TINA MICHELLE CLARK |
| NPI Number: | 1104030899 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | RC00049995 |
| Business Practice Address: | 135 W Main St Chehalis, WA - 985324817 |
| Business Phone Number: | 3607486696 |
| Business Fax Number: | |
| Mailing Address: | 1313 Ferrier Rd, WINLOCK |
| State: | WA |
| Postal Code: | 985969330 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 05/10/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | RC00049995 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |