Provider Demographics
NPI:1881884443
Name:CLARK, TAMERA D (ND, SLP)
Entity type:Individual
Prefix:DR
First Name:TAMERA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:ND, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 GLADE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-4381
Mailing Address - Country:US
Mailing Address - Phone:817-381-6637
Mailing Address - Fax:817-549-6368
Practice Address - Street 1:1116 GLADE RD STE 102
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4381
Practice Address - Country:US
Practice Address - Phone:682-738-6543
Practice Address - Fax:817-549-6368
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101962235Z00000X
175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty