Provider Demographics
NPI:1689824807
Name:DECLARK, JANET LOUISE
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:LOUISE
Last Name:DECLARK
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:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-0345
Mailing Address - Country:US
Mailing Address - Phone:970-390-4180
Mailing Address - Fax:
Practice Address - Street 1:388 EAGLE CREST RD.
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-0345
Practice Address - Country:US
Practice Address - Phone:970-390-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist