Provider Demographics
NPI:1922230697
Name:CLARK, ELIZABETH LAND (MS-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LAND
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 N WOODSTOCK ST
Mailing Address - Street 2:APARTMENT 201
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-2431
Mailing Address - Country:US
Mailing Address - Phone:571-212-4685
Mailing Address - Fax:
Practice Address - Street 1:7617 LITTLE RIVER TPKE
Practice Address - Street 2:SUITE #310
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2603
Practice Address - Country:US
Practice Address - Phone:703-941-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist