Provider Demographics
NPI:1992839112
Name:CLARK, NILA M (SLP)
Entity Type:Individual
Prefix:MRS
First Name:NILA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 N GEIGER ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-1342
Mailing Address - Country:US
Mailing Address - Phone:812-683-2531
Mailing Address - Fax:812-683-2531
Practice Address - Street 1:419 N GEIGER ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-1342
Practice Address - Country:US
Practice Address - Phone:812-683-2531
Practice Address - Fax:812-683-2531
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22000444A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist