Provider Demographics
NPI:1619121357
Name:CLARK, KELLY J (MS CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:J
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 - Credentials:
Mailing Address - Street 1:1 ADLER DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1223
Mailing Address - Country:US
Mailing Address - Phone:315-701-7900
Mailing Address - Fax:315-701-7901
Practice Address - Street 1:2100 BRIGHTON HENRIETTA TOWN LINE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2785
Practice Address - Country:US
Practice Address - Phone:585-697-5692
Practice Address - Fax:585-697-5692
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015027235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist