Provider Demographics
NPI:1083186209
Name:CLARK, JOAN LESLIE (EDS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:LESLIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:EDS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7379 SHELL RIDGE TERRACE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7883
Mailing Address - Country:US
Mailing Address - Phone:561-596-6670
Mailing Address - Fax:561-434-7307
Practice Address - Street 1:3898 VIA POINCIANA STE 17
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2951
Practice Address - Country:US
Practice Address - Phone:561-613-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5635235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist