Provider Demographics
NPI:1376675710
Name:CLARK, CLARE BLAKE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:BLAKE
Last Name:CLARK
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 1:1155 GHOLSON RD
Mailing Address - Street 2:
Mailing Address - City:WEST PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42086-9738
Mailing Address - Country:US
Mailing Address - Phone:270-210-3422
Mailing Address - Fax:800-464-0431
Practice Address - Street 1:1155 GHOLSON RD
Practice Address - Street 2:
Practice Address - City:WEST PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42086-9738
Practice Address - Country:US
Practice Address - Phone:270-210-3422
Practice Address - Fax:800-464-0431
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-2643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1890OtherFIRST STEPS PROVIDER-CBIS