Provider Demographics
NPI:1720574957
Name:CLARK, TARA (MS, CF-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 E LANE DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-6633
Mailing Address - Country:US
Mailing Address - Phone:832-474-9814
Mailing Address - Fax:
Practice Address - Street 1:5038 CHAMPIONS DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-7346
Practice Address - Country:US
Practice Address - Phone:832-539-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist