Provider Demographics
NPI:1578085924
Name:CLARK, LENNEE (PSS)
Entity Type:Individual
Prefix:
First Name:LENNEE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSS
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 5
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0001
Mailing Address - Country:US
Mailing Address - Phone:541-942-3939
Mailing Address - Fax:541-942-9310
Practice Address - Street 1:75 S 5TH ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2008
Practice Address - Country:US
Practice Address - Phone:541-767-4260
Practice Address - Fax:541-649-1697
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW2138101YA0400X
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)