Provider Demographics
NPI:1518226216
Name:CLARK, LEONARD (CERTIFIED ALCOHOL &)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:CERTIFIED ALCOHOL &
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 11629
Mailing Address - Street 2:4134 N. VANCOUVER AVE., SUITE 303C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2900
Mailing Address - Country:US
Mailing Address - Phone:503-593-7764
Mailing Address - Fax:
Practice Address - Street 1:4134 N. VANCOUVER AVE., SUITE 303C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2900
Practice Address - Country:US
Practice Address - Phone:503-593-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR06-R-06OtherCADC II