Provider Demographics
NPI:1437393469
Name:CLARK, ELIZABETH LARSON
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LARSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 DARTMOORE LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3340
Mailing Address - Country:US
Mailing Address - Phone:678-947-5239
Mailing Address - Fax:678-668-7445
Practice Address - Street 1:4760 DARTMOORE LN
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3340
Practice Address - Country:US
Practice Address - Phone:678-947-5239
Practice Address - Fax:678-668-7445
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007062235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist