Provider Demographics
NPI:1841218732
Name:CLARK, STACI M (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:M
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 1:200 BROUGHTON DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-3841
Mailing Address - Country:US
Mailing Address - Phone:864-233-7905
Mailing Address - Fax:864-233-7905
Practice Address - Street 1:355 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2537
Practice Address - Country:US
Practice Address - Phone:864-595-4225
Practice Address - Fax:864-595-4821
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist