Provider Demographics
NPI:1003482654
Name:CLARK, KATRINA ANN (CSWA)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 SE UMATILLA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7414
Mailing Address - Country:US
Mailing Address - Phone:808-343-2163
Mailing Address - Fax:
Practice Address - Street 1:1715 E BURNSIDE ST STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1531
Practice Address - Country:US
Practice Address - Phone:808-343-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA50911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical