Provider Demographics
NPI:1609373166
Name:CLARK-MCKITRICK, BLYTHE PATRICIA
Entity Type:Individual
Prefix:
First Name:BLYTHE
Middle Name:PATRICIA
Last Name:CLARK-MCKITRICK
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 1:10763 SW GREENBURG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5492
Mailing Address - Country:US
Mailing Address - Phone:503-941-8569
Mailing Address - Fax:503-598-0934
Practice Address - Street 1:10763 SW GREENBURG RD STE 100
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5492
Practice Address - Country:US
Practice Address - Phone:503-941-8569
Practice Address - Fax:503-598-0934
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)