Provider Demographics
NPI:1316368152
Name:CLARK, KATHERINE E
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:11981 RUDDY RUN
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4095
Mailing Address - Country:US
Mailing Address - Phone:813-525-1323
Mailing Address - Fax:
Practice Address - Street 1:11981 RUDDY RUN
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-4095
Practice Address - Country:US
Practice Address - Phone:813-525-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12208235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist