Provider Demographics
NPI:1740756386
Name:CLARK, LAURA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ISABELLE ISLE APT 101
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-5293
Mailing Address - Country:US
Mailing Address - Phone:814-897-6721
Mailing Address - Fax:
Practice Address - Street 1:20 W FRAZIER ST
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1416
Practice Address - Country:US
Practice Address - Phone:302-653-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEO1-0001590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist