Provider Demographics
NPI:1013205434
Name:CLARK, CARLA CHRISTINE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:CHRISTINE
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:PO BOX 494563
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75049-4563
Mailing Address - Country:US
Mailing Address - Phone:972-271-6000
Mailing Address - Fax:888-755-0789
Practice Address - Street 1:3200 BROADWAY BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1573
Practice Address - Country:US
Practice Address - Phone:214-497-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013205434OtherNPI