Provider Demographics
NPI:1649313040
Name:CLARK, LYNN W (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:W
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 1:3525 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-8943
Mailing Address - Country:US
Mailing Address - Phone:812-838-4740
Mailing Address - Fax:812-838-3115
Practice Address - Street 1:3525 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-8943
Practice Address - Country:US
Practice Address - Phone:812-838-4740
Practice Address - Fax:812-838-3115
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003481A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist