Provider Demographics
NPI:1457506537
Name:CLARK, GAIL ELIZABETH (MA/SLP)
Entity Type:Individual
Prefix:MISS
First Name:GAIL
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 MARATHON PKWY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2043
Mailing Address - Country:US
Mailing Address - Phone:917-692-3568
Mailing Address - Fax:
Practice Address - Street 1:6116 MARATHON PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-2043
Practice Address - Country:US
Practice Address - Phone:917-692-3568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008512-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist