Provider Demographics
NPI:1679021448
Name:CLARK, SHANNON LORRAINE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LORRAINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 WILLOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-8753
Mailing Address - Country:US
Mailing Address - Phone:616-828-3879
Mailing Address - Fax:
Practice Address - Street 1:2251 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2431
Practice Address - Country:US
Practice Address - Phone:616-447-7799
Practice Address - Fax:616-724-4117
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist