Provider Demographics
NPI:1245456409
Name:CLARK, MARIOLA D (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARIOLA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 FERN DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-2580
Mailing Address - Country:US
Mailing Address - Phone:505-749-2795
Mailing Address - Fax:505-622-6703
Practice Address - Street 1:412 N RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4731
Practice Address - Country:US
Practice Address - Phone:505-623-2615
Practice Address - Fax:505-622-6703
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist