Provider Demographics
NPI:1598736035
Name:CLARK, DIANA MARTHA (LCSW MSW MA DMIN)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARTHA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW MSW MA DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 SW BOONES FERRY RD
Mailing Address - Street 2:STE 850
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3423
Mailing Address - Country:US
Mailing Address - Phone:503-636-1625
Mailing Address - Fax:503-635-9127
Practice Address - Street 1:15100 SW BOONES FERRY RD
Practice Address - Street 2:STE 850
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3423
Practice Address - Country:US
Practice Address - Phone:503-636-1625
Practice Address - Fax:503-635-9127
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical