Provider Demographics
NPI:1184083438
Name:YOUNG, CLARK G (MS, QMHP)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:G
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MS, QMHP
Other - Prefix:
Other - First Name:ALYCE
Other - Middle Name:R
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2361 SE 116TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-4016
Mailing Address - Country:US
Mailing Address - Phone:337-794-3936
Mailing Address - Fax:
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-253-6754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORR8305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor