Provider Demographics
NPI:1073865655
Name:CLARKE, KAITLYN (MSLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 PIERCE ST STE 309
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5512
Mailing Address - Country:US
Mailing Address - Phone:570-855-5592
Mailing Address - Fax:877-407-4329
Practice Address - Street 1:480 PIERCE ST STE 309
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5512
Practice Address - Country:US
Practice Address - Phone:570-855-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010763235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist