Basic Information
| Provider Information | |||||||||
| NPI: | 1407251408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | NICKLAUS | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 NW CIVIC DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2014 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60497951 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C3550 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 2012024654 | MO | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.