Provider Demographics
NPI:1245569326
Name:CLARK, ANNE W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANNE
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE.210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:9000 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3006
Practice Address - Country:US
Practice Address - Phone:503-988-5304
Practice Address - Fax:503-988-5305
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR022959Medicaid
OR096511Medicaid