Basic Information
| Provider Information | |||||||||
| NPI: | 1699928937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 W 11TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416862688 | ||||||||
| FaxNumber: | 5413457605 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414844428 | ||||||||
| FaxNumber: | 5414847212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 390200000X | RC60018186 | WA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.