Provider Demographics
NPI:1497162176
Name:CLARK, MARY CATHERINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 HAPPY LN
Mailing Address - Street 2:#20
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1847
Mailing Address - Country:US
Mailing Address - Phone:541-852-1733
Mailing Address - Fax:
Practice Address - Street 1:100 RIVER AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2507
Practice Address - Country:US
Practice Address - Phone:541-345-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical