Healthcare Provider Details

I. General information

NPI: 1104173970
Provider Name (Legal Business Name): KATIE JOHNSON CLARK MA, LPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHARINE JOHNSON CLARK MA, LPC, LMHC

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 NE DALLAS ST STE 208
CAMAS WA
98607-2189
US

IV. Provider business mailing address

416 NE DALLAS ST STE 208
CAMAS WA
98607-2189
US

V. Phone/Fax

Practice location:
  • Phone: 503-781-1997
  • Fax: 503-200-1138
Mailing address:
  • Phone: 503-781-1997
  • Fax: 503-200-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3201
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61095149
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: