MEDICARE: SUSAN MARIE CLARK M. ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	RC00039358	WA
2	101YP2500X	Professional Counselor	RC00039358	WA

General Provider Information

NPI Number	:	1245291079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE CLARK M. ED.

Provider Business Mailing Address
First Line	:	PO BOX 426
Second Line	:
City	:	ABERDEEN
State	:	WA
Zip	:	98520-0099
Country	:	US
Telephone Number	:	360-249-4149
Fax Number	:	360-249-4149

Provider Business Practice Location Address
First Line	:	12 SATSOP CT
Second Line	:
City	:	MONTESANO
State	:	WA
Zip	:	98563-9785
Country	:	US
Telephone Number	:	360-249-4149
Fax Number	:	360-249-4149

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	09/11/2025

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