Provider Demographics
NPI:1508210915
Name:CLARK, KIMBERLY SUE (QMHP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:DUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT ASSOCIATE
Mailing Address - Street 1:1500 ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-2504
Mailing Address - Country:US
Mailing Address - Phone:541-591-9392
Mailing Address - Fax:541-833-0934
Practice Address - Street 1:905 MAIN ST STE 512
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6062
Practice Address - Country:US
Practice Address - Phone:541-591-9392
Practice Address - Fax:541-833-0934
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-04-02101YA0400X
ORR6418101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1114058898Medicaid