Healthcare Provider Details

I. General information

NPI: 1275003873
Provider Name (Legal Business Name): ANGELA CLARK MSW,LICSWA, MCA,SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N. PINES
SPOKANE WA
99206
US

IV. Provider business mailing address

107 S DIVISION ST
SPOKANE WA
99202-1510
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4651
  • Fax: 509-326-5025
Mailing address:
  • Phone: 509-838-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMC61249881
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60656762
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC60656780
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: