Provider Demographics
NPI:1780972174
Name:CLARK, EMILY BURZYNSKI (SLP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BURZYNSKI
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARGARET
Other - Last Name:BURZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 130
Mailing Address - Street 2:201 S. PARK ST. VILLA PINES LIVING CENTER
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934
Mailing Address - Country:US
Mailing Address - Phone:608-339-3361
Mailing Address - Fax:
Practice Address - Street 1:210 S. PARK ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934
Practice Address - Country:US
Practice Address - Phone:608-339-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3558-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist