Provider Demographics
NPI:1629810171
Name:CLARK, WILLIAM LEE (CRM, THW, CADC-R)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRM, THW, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17518 SE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97267-5635
Mailing Address - Country:US
Mailing Address - Phone:719-907-6289
Mailing Address - Fax:
Practice Address - Street 1:17518 SE RIVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97267-5635
Practice Address - Country:US
Practice Address - Phone:971-990-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health