Provider Demographics
NPI:1801129267
Name:CLARK, CHRISTINA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 NE 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3660
Mailing Address - Country:US
Mailing Address - Phone:917-912-9505
Mailing Address - Fax:
Practice Address - Street 1:2143 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:917-912-9505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical