Provider Demographics
NPI:1093911786
Name:CLARK, BOBBIE JEAN (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:BOBBIE
Middle Name:JEAN
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 1:811 PARK ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2239
Mailing Address - Country:US
Mailing Address - Phone:307-921-1535
Mailing Address - Fax:
Practice Address - Street 1:811 PARK ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2239
Practice Address - Country:US
Practice Address - Phone:307-921-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315047OtherBCBS
WY315047OtherBCBS