Provider Demographics
NPI:1255174413
Name:CLARK, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
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 52
Mailing Address - Street 2:
Mailing Address - City:LANE
Mailing Address - State:OK
Mailing Address - Zip Code:74555-0052
Mailing Address - Country:US
Mailing Address - Phone:972-439-6569
Mailing Address - Fax:
Practice Address - Street 1:1211 E LINCOLN RD STE B
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7342
Practice Address - Country:US
Practice Address - Phone:972-439-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCF675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist