Provider Demographics
NPI:1477640167
Name:CLARKE, ELIZABETH F (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:F
Last Name:CLARKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 NORTH MAPLE GLADE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382
Mailing Address - Country:US
Mailing Address - Phone:404-290-4960
Mailing Address - Fax:888-278-6692
Practice Address - Street 1:283 NORTH MAPLE GLADE CIRCLE
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382
Practice Address - Country:US
Practice Address - Phone:404-290-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP0004320235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000792833CMedicaid