Provider Demographics
NPI:1114231784
Name:CLARK, CHRISTIE B (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 E LONG BAY DR
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-5916
Mailing Address - Country:US
Mailing Address - Phone:864-308-8004
Mailing Address - Fax:864-345-8446
Practice Address - Street 1:787 E LONG BAY DR
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-5916
Practice Address - Country:US
Practice Address - Phone:864-308-8004
Practice Address - Fax:864-345-8446
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3753235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1124Medicaid