Provider Demographics
NPI:1760768188
Name:CLARK, KAYLA MARIE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5355 TALLMAN AVE NW STE 210
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3954
Mailing Address - Country:US
Mailing Address - Phone:206-414-8260
Mailing Address - Fax:
Practice Address - Street 1:5355 TALLMAN AVE NW STE 210
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3954
Practice Address - Country:US
Practice Address - Phone:206-414-8260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605936291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical