Healthcare Provider Details

I. General information

NPI: 1043137961
Provider Name (Legal Business Name): LISA ANN CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 S CHASE ST
PORT ANGELES WA
98362-6122
US

IV. Provider business mailing address

2605 CALAWAH WAY
FORKS WA
98331-9712
US

V. Phone/Fax

Practice location:
  • Phone: 306-203-6997
  • Fax:
Mailing address:
  • Phone: 360-203-6997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61519991
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: