MEDICARE: CLARK COLLEGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	PY60267694	WA

General Provider Information

NPI Number	:	1285047258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK COLLEGE

Provider Business Mailing Address
First Line	:	1933 FORT VANCOUVER WAY
Second Line	:	HSC 124
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3529
Country	:	US
Telephone Number	:	360-992-2614
Fax Number	:

Provider Business Practice Location Address
First Line	:	1933 FORT VANCOUVER WAY
Second Line	:	HSC 124
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3529
Country	:	US
Telephone Number	:	360-992-2614
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPERVISOR
Name	:	PATRICIA DOUGLASS
Credential	:	LICSW
Telephone Number	:	360-992-2614

Provider Enumeration Date	:	06/08/2014
Last Update Date	:	06/08/2014

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Directions to “CLARK COLLEGE ” Practice Location

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