Provider Demographics
NPI:1710205232
Name:QUISENBERRY, CLINTON EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:EDWARD
Last Name:QUISENBERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 HUDSON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3046
Mailing Address - Country:US
Mailing Address - Phone:503-747-4646
Mailing Address - Fax:503-214-8668
Practice Address - Street 1:1516 HUDSON ST STE 204
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3046
Practice Address - Country:US
Practice Address - Phone:503-747-4646
Practice Address - Fax:503-214-8668
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2721103T00000X
WAPY60132400103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist