Healthcare Provider Details

I. General information

NPI: 1215890710
Provider Name (Legal Business Name): KATIE A CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 SW 46TH ST
PENDLETON OR
97801-3721
US

IV. Provider business mailing address

1416 SW 46TH ST
PENDLETON OR
97801-3721
US

V. Phone/Fax

Practice location:
  • Phone: 541-310-1971
  • Fax:
Mailing address:
  • Phone: 541-310-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: