Provider Demographics
NPI:1871641084
Name:CLARK, DEANNA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 IONA CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3341
Mailing Address - Country:US
Mailing Address - Phone:907-344-6042
Mailing Address - Fax:907-644-2808
Practice Address - Street 1:4021 IONA CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3341
Practice Address - Country:US
Practice Address - Phone:907-344-6042
Practice Address - Fax:907-644-2808
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK39235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK39OtherPROFESSIONAL SLP LICENSE
AKSP9180Medicaid