Healthcare Provider Details

I. General information

NPI: 1760715148
Provider Name (Legal Business Name): LAURA MARIE CLARK MSW, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA MARIE STORM MSW, MA

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NE 109TH AVE
VANCOUVER WA
98682-7749
US

IV. Provider business mailing address

3200 NE 109TH AVE
VANCOUVER WA
98682-7749
US

V. Phone/Fax

Practice location:
  • Phone: 360-695-1014
  • Fax:
Mailing address:
  • Phone: 360-695-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: