Individual
CARLY A CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSS
Contact information
Practice address
620 NE 2ND ST, GRESHAM, OR 97030-7514
(971) 274-3757
Mailing address
1776 SW MADISON ST, PORTLAND, OR 97205-1715
(503) 224-1044
(503) 621-2235
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
—
WA
175T00000X
Peer Specialist
Primary
THW000107924
OR
Other
Enumeration date
03/16/2023
Last updated
03/16/2023
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