Provider Demographics
NPI:1740787027
Name:CLARK, COURTNEY N (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N KLEIN CIR
Mailing Address - Street 2:ATTENT: THERAPY DEPT.
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-440-9617
Mailing Address - Fax:
Practice Address - Street 1:731 N KLEIN CIR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-7011
Practice Address - Country:US
Practice Address - Phone:316-440-9617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist