Provider Demographics
NPI:1255687828
Name:CLARKE, NICOLE ELAINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELAINE
Last Name:CLARKE
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 1:1814 FALLSTAFF CT
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6274
Mailing Address - Country:US
Mailing Address - Phone:410-795-3781
Mailing Address - Fax:
Practice Address - Street 1:1814 FALLSTAFF CT
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6274
Practice Address - Country:US
Practice Address - Phone:410-795-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05627235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist