Provider Demographics
NPI:1306688643
Name:HENRY, CLIFFORD CHEPO NATHANIEL
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:CHEPO NATHANIEL
Last Name:HENRY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 SE STARK ST STE 211
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2313
Mailing Address - Country:US
Mailing Address - Phone:720-273-3479
Mailing Address - Fax:
Practice Address - Street 1:7831 SE STARK ST STE 211
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2313
Practice Address - Country:US
Practice Address - Phone:720-273-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist