Healthcare Provider Details

I. General information

NPI: 1699118935
Provider Name (Legal Business Name): CAMM D. CLARK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 W. 12TH AVENUE
EUGENE OR
97401-6215
US

IV. Provider business mailing address

687 CHESHIRE AVENUE
EUGENE OR
97402-5060
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-4400
  • Fax: 541-344-0772
Mailing address:
  • Phone: 541-762-4400
  • Fax: 541-344-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA3225
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6545
License Number StateOR

VII. Legacy identifiers

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

# 1
IdentifierL6545
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerLCSW

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: