Provider Demographics
NPI:1194185314
Name:CLARK, AIMEE LYNNELLE (BS CADCI)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:LYNNELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-3227
Mailing Address - Country:US
Mailing Address - Phone:541-510-3270
Mailing Address - Fax:
Practice Address - Street 1:616 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4339
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-08-21U101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)