Provider Demographics
NPI:1174133953
Name:PETTIS-CLARK, LAURA ANNE (QMHA-R)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:PETTIS-CLARK
Suffix:
Gender:F
Credentials:QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 NE 165TH DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5525
Mailing Address - Country:US
Mailing Address - Phone:971-285-2476
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE STE 340
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7903
Practice Address - Country:US
Practice Address - Phone:503-655-8045
Practice Address - Fax:523-655-6806
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator