Provider Demographics
NPI:1255734018
Name:CLARK, TERRY LEE (MED, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:TERRY
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 GLADES RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6424
Mailing Address - Country:US
Mailing Address - Phone:561-297-4026
Mailing Address - Fax:561-297-2268
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-297-4026
Practice Address - Fax:561-297-2268
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist