Provider Demographics
NPI:1467186767
Name:CLARK, KELLY SUSANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:65070 E LUPINE DR
Mailing Address - Street 2:
Mailing Address - City:RHODODENDRON
Mailing Address - State:OR
Mailing Address - Zip Code:97049-9771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health