Provider Demographics
NPI:1073011847
Name:MINER, CLARK (CADC II, QMHA II)
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:
Last Name:MINER
Suffix:
Gender:M
Credentials:CADC II, QMHA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 NE 78TH CT STE A3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2823
Mailing Address - Country:US
Mailing Address - Phone:503-252-3949
Mailing Address - Fax:503-252-4027
Practice Address - Street 1:6601 NE 78TH CT STE A3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-2823
Practice Address - Country:US
Practice Address - Phone:503-252-3949
Practice Address - Fax:503-252-4027
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-01-07101YA0400X
OR21-11-20118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)