Individual
NICKLAUS CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPC, LMHC
Contact information
Practice address
1700 NW CIVIC DR, SUITE 310, GRESHAM, OR 97030-3770
(503) 233-5405
Mailing address
PO BOX 82819, PORTLAND, OR 97282-0819
(503) 233-5405
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
LH60497951
WA
101YP2500X
Professional Counselor
2012024654
MO
101YP2500X
Professional Counselor
Primary
C3550
OR
Other
Enumeration date
11/03/2014
Last updated
02/04/2016
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