Provider Demographics
NPI:1669541223
Name:CLARKE, VICKI KNOWLES (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:KNOWLES
Last Name:CLARKE
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 1:183 HIGHCREST DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5993
Mailing Address - Country:US
Mailing Address - Phone:678-521-4692
Mailing Address - Fax:866-384-6451
Practice Address - Street 1:3105 CREEKSIDE VILLAGE DR NW STE 603
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4218
Practice Address - Country:US
Practice Address - Phone:770-974-2424
Practice Address - Fax:866-384-6541
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA SLP 003536235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00675441CMedicaid