Provider Demographics
NPI:1790844579
Name:CLARK, LAMONT L (MA-CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:LAMONT
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
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 1:3725 N FARM ROAD 79
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-8155
Mailing Address - Country:US
Mailing Address - Phone:417-773-0384
Mailing Address - Fax:
Practice Address - Street 1:940 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3718
Practice Address - Country:US
Practice Address - Phone:417-773-0384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0296200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist