Healthcare Provider Details

I. General information

NPI: 1740729599
Provider Name (Legal Business Name): TAYLOR CLARK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MAIN ST
BAKER CITY OR
97814-2655
US

IV. Provider business mailing address

2100 MAIN ST
BAKER CITY OR
97814-2655
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-7400
  • Fax: 541-523-4927
Mailing address:
  • Phone: 541-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4730
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: