Provider Demographics
NPI:1649527912
Name:CLARK, CHRISTOPHER COLIN (BS, MA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:COLIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:BS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:2375 NW GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3420
Practice Address - Country:US
Practice Address - Phone:503-243-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No372600000XNursing Service Related ProvidersAdult Companion