Provider Demographics
NPI:1558772152
Name:ROBERTS, CLANCY
Entity Type:Individual
Prefix:
First Name:CLANCY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
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 4399
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4399
Mailing Address - Country:US
Mailing Address - Phone:503-413-1600
Mailing Address - Fax:503-413-1915
Practice Address - Street 1:501 N GRAHAM ST STE 375
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2001
Practice Address - Country:US
Practice Address - Phone:503-413-1600
Practice Address - Fax:503-413-1915
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL73911041C0700X
WACG60463999101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health