Provider Demographics
NPI:1619585221
Name:CLARK, BREANNE ARIEL
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:ARIEL
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 1:132 E BROADWAY STE 303
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3154
Mailing Address - Country:US
Mailing Address - Phone:541-525-4460
Mailing Address - Fax:541-833-4033
Practice Address - Street 1:132 E BROADWAY STE 303
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3154
Practice Address - Country:US
Practice Address - Phone:541-525-4460
Practice Address - Fax:541-833-4033
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health