Provider Demographics
NPI:1609932490
Name:CLARK, ROBERT MARC (LCSW LICENSED CLINIC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARC
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW LICENSED CLINIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 NW 7TH STR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801
Mailing Address - Country:US
Mailing Address - Phone:541-276-4017
Mailing Address - Fax:541-278-3353
Practice Address - Street 1:200 SE HAILEY AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-1329
Practice Address - Country:US
Practice Address - Phone:541-276-4017
Practice Address - Fax:541-278-3353
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL07511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical