Provider Demographics
NPI:1568092559
Name:CLARK, GABRIELLE L (SLP)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:L
Other - Last Name:AMBROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1185 W CARMEL DR STE D1A
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8708
Practice Address - Country:US
Practice Address - Phone:317-450-4180
Practice Address - Fax:317-324-3950
Is Sole Proprietor?:No
Enumeration Date:2020-01-19
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006568A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00139223OtherRAILROAD PTAN
IN264430A72OtherMEDICARE PTAN
IN300034682Medicaid
IN063220046OtherMEDICARE PTAN
INQ00478549OtherRAILROAD PTAN