Provider Demographics
NPI:1558939637
Name:CLARK, CHRISTINE (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 SW WOODS CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1330
Mailing Address - Country:US
Mailing Address - Phone:713-594-6969
Mailing Address - Fax:
Practice Address - Street 1:6150 SW WOODS CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-1330
Practice Address - Country:US
Practice Address - Phone:971-350-9817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4719101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty