Healthcare Provider Details

I. General information

NPI: 1194433250
Provider Name (Legal Business Name): CONNECTED SPACE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE 223RD AVE STE 165
GRESHAM OR
97030-2577
US

IV. Provider business mailing address

1201 SE 223RD AVE STE 165
GRESHAM OR
97030-2577
US

V. Phone/Fax

Practice location:
  • Phone: 971-404-4668
  • Fax: 971-273-2708
Mailing address:
  • Phone: 971-404-4668
  • Fax: 971-273-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: FRANCES LEANNE CLARK
Title or Position: OWNER
Credential: MA, LPC
Phone: 503-444-1190