Healthcare Provider Details

I. General information

NPI: 1063761716
Provider Name (Legal Business Name): CLARK PAUL RECTOR PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2012
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR
GRESHAM OR
97030-3770
US

IV. Provider business mailing address

2728 DURANT AVE
BERKELEY CA
94704-1725
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax: 503-669-8641
Mailing address:
  • Phone: 707-494-5840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3245
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: