Healthcare Provider Details

I. General information

NPI: 1891219267
Provider Name (Legal Business Name): MICHAEL CLARKE LMHCA, SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3713 PACIFIC AVE STE E
TACOMA WA
98418-7845
US

IV. Provider business mailing address

3713 PACIFIC AVE STE E
TACOMA WA
98418-7845
US

V. Phone/Fax

Practice location:
  • Phone: 253-433-7993
  • Fax: 253-540-6886
Mailing address:
  • Phone: 253-433-7993
  • Fax: 253-540-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60917997
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: