Healthcare Provider Details

I. General information

NPI: 1427517234
Provider Name (Legal Business Name): BETHANEY CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E POWELL BLVD STE 303
GRESHAM OR
97030-7620
US

IV. Provider business mailing address

4233 SE 182ND AVE # 212
GRESHAM OR
97030-5082
US

V. Phone/Fax

Practice location:
  • Phone: 971-220-1495
  • Fax:
Mailing address:
  • Phone: 971-220-1495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

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: