Provider Demographics
NPI:1710147798
Name:CLARK, BRENDA S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
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 1:7501 OTOE PL
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-3636
Mailing Address - Country:US
Mailing Address - Phone:402-486-6649
Mailing Address - Fax:402-484-6413
Practice Address - Street 1:7501 OTOE PL
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-3636
Practice Address - Country:US
Practice Address - Phone:402-486-6649
Practice Address - Fax:402-484-6413
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE924235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251395-00Medicaid