Provider Demographics
NPI:1881192581
Name:CLARK, STACEY (SLP- ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP- ASSISTANT
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:CLARK-ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP-ASSISTANT
Mailing Address - Street 1:936 AMHERST DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-1540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6301 GASTON AVE STE 750
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3922
Practice Address - Country:US
Practice Address - Phone:214-295-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist