Provider Demographics
NPI:1174864458
Name:SHIRK, CLAYTON THOMAS I (SLP)
Entity Type:Individual
Prefix:MR
First Name:CLAYTON
Middle Name:THOMAS
Last Name:SHIRK
Suffix:I
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E BROADWAY BLVD STE 124-316
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5966
Mailing Address - Country:US
Mailing Address - Phone:520-232-2021
Mailing Address - Fax:
Practice Address - Street 1:2260 N ROSEMONT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2137
Practice Address - Country:US
Practice Address - Phone:520-232-2021
Practice Address - Fax:520-232-2553
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP8235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ796078Medicaid