Provider Demographics
NPI:1609011592
Name:CLARK, AMBER S (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 N HIGBEE AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2554
Mailing Address - Country:US
Mailing Address - Phone:208-890-6841
Mailing Address - Fax:
Practice Address - Street 1:898 SW FOURTH AVE.
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:ID
Practice Address - Zip Code:97914-2693
Practice Address - Country:US
Practice Address - Phone:541-881-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13019235Z00000X
ID1821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist