Provider Demographics
NPI:1801935424
Name:CLARK, DEBORAH WILSON (MA)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:WILSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:SUZANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:3555 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:STE 1
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-6509
Mailing Address - Country:US
Mailing Address - Phone:650-854-1980
Mailing Address - Fax:650-854-1987
Practice Address - Street 1:3555 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:STE 1
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6509
Practice Address - Country:US
Practice Address - Phone:650-854-1980
Practice Address - Fax:650-854-1987
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 1833237600000X
CAHA 3829237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0023741Medicaid
CAGR0023741Medicaid