Provider Demographics
NPI:1881050490
Name:CLARK, PHOEBE SAMANTHA (MA, LPC, ATR)
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:SAMANTHA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66975 WEST ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-9283
Mailing Address - Country:US
Mailing Address - Phone:541-203-0970
Mailing Address - Fax:
Practice Address - Street 1:66975 WEST ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-9283
Practice Address - Country:US
Practice Address - Phone:541-203-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5258101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85338559Medicaid