Provider Demographics
NPI:1912233164
Name:CLARK, PATRICIA S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 OLD LEBANON DIRT RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-4316
Mailing Address - Country:US
Mailing Address - Phone:615-509-8133
Mailing Address - Fax:
Practice Address - Street 1:301 WOLVERINE TRL
Practice Address - Street 2:SUITE 201
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5656
Practice Address - Country:US
Practice Address - Phone:615-220-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP 0000003927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist