Provider Demographics
NPI:1922134147
Name:CLARK, MICHELE (CCC,SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials: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:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-0478
Mailing Address - Country:US
Mailing Address - Phone:678-591-0041
Mailing Address - Fax:770-463-3248
Practice Address - Street 1:245 LAWN MARKET
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-1511
Practice Address - Country:US
Practice Address - Phone:678-591-0041
Practice Address - Fax:770-463-3248
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist