Provider Demographics
NPI:1407164858
Name:CLARK, ISRAEL J (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:205 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-3791
Mailing Address - Country:US
Mailing Address - Phone:740-452-4518
Mailing Address - Fax:740-455-6702
Practice Address - Street 1:205 N 7TH ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3791
Practice Address - Country:US
Practice Address - Phone:740-452-4518
Practice Address - Fax:740-455-6702
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9419235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist