Provider Demographics
NPI:1568766756
Name:CLARK, AMY SUE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ERICA CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1074
Mailing Address - Country:US
Mailing Address - Phone:719-369-6862
Mailing Address - Fax:719-941-7314
Practice Address - Street 1:6 ERICA CT
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1074
Practice Address - Country:US
Practice Address - Phone:719-369-6862
Practice Address - Fax:719-941-7314
Is Sole Proprietor?:No
Enumeration Date:2011-01-02
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000301235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95037071Medicaid