Provider Demographics
NPI:1316695000
Name:CLARK, TAYLOR RENEE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 NE 137TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2724
Mailing Address - Country:US
Mailing Address - Phone:503-744-2611
Mailing Address - Fax:
Practice Address - Street 1:3815 NE 137TH PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2724
Practice Address - Country:US
Practice Address - Phone:503-744-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26712225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist