Provider Demographics
NPI:1013365139
Name:CLARK, KARA ELAINE
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:ELAINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
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 667
Mailing Address - Street 2:
Mailing Address - City:GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:44232-0667
Mailing Address - Country:US
Mailing Address - Phone:330-896-9119
Mailing Address - Fax:
Practice Address - Street 1:4700 MASSILLON RD
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720
Practice Address - Country:US
Practice Address - Phone:330-896-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND 2016-265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist