Provider Demographics
NPI:1013221639
Name:CLARK, JOAN CAROL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:CAROL
Last Name:CLARK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4219
Mailing Address - Country:US
Mailing Address - Phone:423-622-1551
Mailing Address - Fax:423-622-1556
Practice Address - Street 1:3207 ROSEMONT DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4219
Practice Address - Country:US
Practice Address - Phone:423-622-1551
Practice Address - Fax:423-622-1556
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000004310235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist