Provider Demographics
NPI:1922587518
Name:EDERY CLARK, CHAGIT (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:CHAGIT
Middle Name:
Last Name:EDERY CLARK
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:DR
Other - First Name:CHAGIT
Other - Middle Name:
Other - Last Name:EDERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD CCC-SLP
Mailing Address - Street 1:5 DUNNWOODY CT
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-9588
Mailing Address - Country:US
Mailing Address - Phone:718-781-6758
Mailing Address - Fax:
Practice Address - Street 1:5 DUNNWOODY CT
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-9588
Practice Address - Country:US
Practice Address - Phone:718-781-6758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist