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General NPI Number Information
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NPI Number | 1285047258
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Entity Type | Organization
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Legal Business Name | CLARK COLLEGE
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Dates
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Enumeration Date | 06/08/2014
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Last Update Date | 06/08/2014
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Provider Practice Location Address
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Address Line | 1933 FORT VANCOUVER WAY HSC 124
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City | VANCOUVER
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State | WA
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Zip | 98663-3529
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Country | US
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Telephone | 360-992-2614
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Fax |
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Provider Business Mailing Address
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Address Line | 1933 FORT VANCOUVER WAY HSC 124
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City | VANCOUVER
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State | WA
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Zip | 98663-3529
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Country | US
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Telephone | 360-992-2614
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Fax |
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Authorized Official
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Title or Position | CLINICAL SUPERVISOR
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Name | PATRICIA DOUGLASS
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Credential | LICSW
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Telephone | 360-992-2614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | PY60267694
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License Number State | WA
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