Provider Demographics
NPI:1104173970
Name:CLARK, KATIE JOHNSON (MA, LPC, LMHC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JOHNSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC, LMHC
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC, LMHC
Mailing Address - Street 1:416 NE DALLAS ST STE 207
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2189
Mailing Address - Country:US
Mailing Address - Phone:503-781-1997
Mailing Address - Fax:503-200-1138
Practice Address - Street 1:416 NE DALLAS ST STE 207
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2189
Practice Address - Country:US
Practice Address - Phone:503-781-1997
Practice Address - Fax:503-200-1138
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61095149101YM0800X
ORC3201101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
45-2768922OtherEIN #