Provider Demographics
NPI:1740927326
Name:CLARK, KRISTEN MICHAELA
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHAELA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CALVERT DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-2905
Mailing Address - Country:US
Mailing Address - Phone:516-364-1829
Mailing Address - Fax:
Practice Address - Street 1:25 N YEW ST
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1435
Practice Address - Country:US
Practice Address - Phone:516-669-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist