Provider Demographics
NPI:1255119004
Name:CLARK, LAURA RENE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:RENE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:RENE
Other - Last Name:ROMERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1940 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-1804
Mailing Address - Country:US
Mailing Address - Phone:405-521-1217
Mailing Address - Fax:
Practice Address - Street 1:615 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7440
Practice Address - Country:US
Practice Address - Phone:405-587-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist