Provider Demographics
NPI:1407251408
Name:CLARK, NICKLAUS (LPC, LMHC)
Entity Type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:
Practice Address - Street 1:1700 NW CIVIC DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3770
Practice Address - Country:US
Practice Address - Phone:503-233-5405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60497951101YM0800X
ORC3550101YP2500X
MO2012024654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health