1598736035 NPI number — MS. DIANA MARTHA CLARK LCSW MSW MA DMIN

Table of content: MS. DIANA MARTHA CLARK LCSW MSW MA DMIN (NPI 1598736035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598736035 NPI number — MS. DIANA MARTHA CLARK LCSW MSW MA DMIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DIANA
Provider Middle Name:
MARTHA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW MSW MA DMIN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598736035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15100 SW BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE 850
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-636-1625
Provider Business Mailing Address Fax Number:
503-635-9127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15100 SW BOONES FERRY RD
Provider Second Line Business Practice Location Address:
STE 850
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-636-1625
Provider Business Practice Location Address Fax Number:
503-635-9127
Provider Enumeration Date:
02/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1594 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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