Provider Demographics
NPI:1760546428
Name:CLARK, MELISSA ANN (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:HATFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD, CCC-SLP
Mailing Address - Street 1:6320 CANOGA AVE FL 15
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2563
Mailing Address - Country:US
Mailing Address - Phone:818-894-2273
Mailing Address - Fax:818-357-2505
Practice Address - Street 1:9431 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5879
Practice Address - Country:US
Practice Address - Phone:818-894-2273
Practice Address - Fax:818-357-2505
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X321OtherBLUE CROSS BLUE SHIELD
AR149195721Medicaid