Provider Demographics
NPI:1639311970
Name:CLARKE, MOLLIE CAMPBELL (MOLLIE CLARKE, LPC)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:CAMPBELL
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MOLLIE CLARKE, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 SE ASH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1526
Mailing Address - Country:US
Mailing Address - Phone:503-233-6625
Mailing Address - Fax:
Practice Address - Street 1:1732 SE ASH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1526
Practice Address - Country:US
Practice Address - Phone:503-233-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health