Healthcare Provider Details

I. General information

NPI: 1306688643
Provider Name (Legal Business Name): CLIFFORD CHEPO NATHANIEL HENRY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7831 SE STARK ST STE 211
PORTLAND OR
97215-2313
US

IV. Provider business mailing address

7831 SE STARK ST STE 211
PORTLAND OR
97215-2313
US

V. Phone/Fax

Practice location:
  • Phone: 720-273-3479
  • Fax:
Mailing address:
  • Phone: 720-273-3479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR9681
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: