Provider Demographics
NPI:1952002883
Name:CLARK, MAKENNA KATHERINE (MS-SLP)
Entity Type:Individual
Prefix:MS
First Name:MAKENNA
Middle Name:KATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8651 STEPHENS CHURCH RD APT C106
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7982
Mailing Address - Country:US
Mailing Address - Phone:828-443-8925
Mailing Address - Fax:
Practice Address - Street 1:3901 WRIGHTSVILLE AVENUE
Practice Address - Street 2:SUITE 120
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-679-8385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30000920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist