Provider Demographics
NPI:1699928937
Name:CLARK, CRYSTAL L (RC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 W 11TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3871
Mailing Address - Country:US
Mailing Address - Phone:541-686-2688
Mailing Address - Fax:541-345-7605
Practice Address - Street 1:260 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3247
Practice Address - Country:US
Practice Address - Phone:541-484-4428
Practice Address - Fax:541-484-7212
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC60018186390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program