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General NPI Number Information
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NPI Number | 1124539879
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Entity Type | Individual
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Provider Name | CLEMENT NISBET WILSON FONSECA LCSW
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Gender | Male
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Dates
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Enumeration Date | 10/21/2017
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 3125B NE HOLLADAY ST
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City | PORTLAND
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State | OR
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Zip | 97232-2504
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Country | US
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Telephone | 503-217-4457
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11764
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City | PORTLAND
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State | OR
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Zip | 97211-0764
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Country | US
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Telephone | 857-498-0287
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L11642
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License Number State | OR
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