Provider Demographics
NPI:1700116647
Name:CLARK, KRYSTIN LOUISE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KRYSTIN
Other - Middle Name:LOUISE
Other - Last Name:BOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:4300 MULLIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3475
Mailing Address - Country:US
Mailing Address - Phone:314-283-6747
Mailing Address - Fax:
Practice Address - Street 1:4300 MULLIGAN AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3475
Practice Address - Country:US
Practice Address - Phone:314-283-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-27
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112024235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist