MEDICARE: MR. LEONARD CLARK CERTIFIED ALCOHOL &

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06-R-06	OTHER	OR	CADC II

General Provider Information

NPI Number	:	1518226216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEONARD CLARK CERTIFIED ALCOHOL &

Provider Business Mailing Address
First Line	:	PO BOX 11629
Second Line	:	4134 N. VANCOUVER AVE., SUITE 303C
City	:	PORTLAND
State	:	OR
Zip	:	97217-2900
Country	:	US
Telephone Number	:	503-593-7764
Fax Number	:

Provider Business Practice Location Address
First Line	:	4134 N. VANCOUVER AVE., SUITE 303C
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-2900
Country	:	US
Telephone Number	:	503-593-7764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	05/15/2012

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