Provider Demographics
NPI:1013337112
Name:CLARK, MAX
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11919 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2144
Mailing Address - Country:US
Mailing Address - Phone:503-408-0972
Mailing Address - Fax:
Practice Address - Street 1:11919 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2144
Practice Address - Country:US
Practice Address - Phone:503-408-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-614565237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist