Basic Information
| Provider Information | |||||||||
| NPI: | 1609373166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK-MCKITRICK | ||||||||
| FirstName: | BLYTHE | ||||||||
| MiddleName: | PATRICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10763 SW GREENBURG RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972235492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039418569 | ||||||||
| FaxNumber: | 5035980934 | ||||||||
| Practice Location | |||||||||
| Address1: | 10763 SW GREENBURG RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972235492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039418569 | ||||||||
| FaxNumber: | 5035980934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T-18-017 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.