Provider Demographics
NPI:1538692249
Name:CLARK, RUSSELL (AUD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 E STATE ST STE 2108
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6232
Mailing Address - Country:US
Mailing Address - Phone:208-385-3480
Mailing Address - Fax:208-385-3481
Practice Address - Street 1:3101 E STATE ST STE 2108
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-385-3480
Practice Address - Fax:208-385-3481
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-1526231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist