Healthcare Provider Details

I. General information

NPI: 1841703428
Provider Name (Legal Business Name): HAILEY CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63311 JAMISON ST
BEND OR
97703-8288
US

IV. Provider business mailing address

PO BOX 579
CORVALLIS OR
97339-0579
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7500
  • Fax: 541-322-7565
Mailing address:
  • Phone: 541-766-6835
  • Fax: 541-766-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC7353
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: