=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518254119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARSKY COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2011
-----------------------------------------------------
Last Update Date | 02/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14511 WESTLAKE DR STE 102
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-7783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-515-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1505 N PONDEROSA ST
-----------------------------------------------------
City | CANBY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97013-2580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-515-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | ROBERT WILLIAM GARBER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 503-515-9391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | L4100
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------