Provider Demographics
NPI:1114176328
Name:CLARK, KATHLEEN CLARK (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CLARK
Last Name:CLARK
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 STATE ROUTE 28
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:THENDARA
Mailing Address - State:NY
Mailing Address - Zip Code:13472-0007
Mailing Address - Country:US
Mailing Address - Phone:315-369-3307
Mailing Address - Fax:
Practice Address - Street 1:2675 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:THENDARA
Practice Address - State:NY
Practice Address - Zip Code:13472-0007
Practice Address - Country:US
Practice Address - Phone:315-369-3307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00834-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist