Provider Demographics
NPI:1003141425
Name:CLARK, SANDRA ELLEN (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:SHIPPENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16254-9022
Mailing Address - Country:US
Mailing Address - Phone:814-782-6342
Mailing Address - Fax:
Practice Address - Street 1:242 MAPLE DR
Practice Address - Street 2:
Practice Address - City:SHIPPENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16254-9022
Practice Address - Country:US
Practice Address - Phone:814-782-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2009-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist