Provider Demographics
NPI:1114248630
Name:CLARK, RAYNELL THERESA (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:RAYNELL
Middle Name:THERESA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25281 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6159
Mailing Address - Country:US
Mailing Address - Phone:248-227-4080
Mailing Address - Fax:
Practice Address - Street 1:25281 LOIS LN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6159
Practice Address - Country:US
Practice Address - Phone:248-227-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist