Provider Demographics
NPI:1295164309
Name:BAYARD-CLARK, MIRANDA (MA, LPC INTERN,)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BAYARD-CLARK
Suffix:
Gender:F
Credentials:MA, LPC INTERN,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 BOONES FERRY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15110 BOONES FERRY RD STE 150
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3486
Practice Address - Country:US
Practice Address - Phone:503-395-7592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60599847101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health