Individual
CLEMENT NISBET WILSON FONSECA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
3125B NE HOLLADAY ST, PORTLAND, OR 97232-2504
(503) 217-4457
Mailing address
PO BOX 11764, PORTLAND, OR 97211-0764
(857) 498-0287
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
L11642
OR
Other
Enumeration date
10/21/2017
Last updated
09/02/2025
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