Provider Demographics
NPI:1700044856
Name:CLARK, CHERYL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2512
Mailing Address - Country:US
Mailing Address - Phone:704-663-2115
Mailing Address - Fax:704-663-2730
Practice Address - Street 1:510 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2512
Practice Address - Country:US
Practice Address - Phone:704-663-2115
Practice Address - Fax:704-663-2730
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7898235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist