Provider Demographics
NPI:1003372269
Name:CLARK, SHELIA
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELIA
Other - Middle Name:
Other - Last Name:CLEMENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1103 NE ELM ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1664
Mailing Address - Country:US
Mailing Address - Phone:541-233-3203
Mailing Address - Fax:541-447-1121
Practice Address - Street 1:1103 NE ELM ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1664
Practice Address - Country:US
Practice Address - Phone:541-323-5330
Practice Address - Fax:541-447-1121
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health