Provider Demographics
NPI:1376973834
Name:CLARK, KRISTI M (MA)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1263
Mailing Address - Country:US
Mailing Address - Phone:304-744-2300
Mailing Address - Fax:304-744-8195
Practice Address - Street 1:313 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1263
Practice Address - Country:US
Practice Address - Phone:304-744-2300
Practice Address - Fax:304-744-8195
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0211231H00000X
OHA.01642231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH225610Medicare PIN