Basic Information
| Provider Information | |||||||||
| NPI: | 1003141425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MS CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 242 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | SHIPPENVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162549022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147826342 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 242 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | SHIPPENVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162549022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147826342 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2009 | ||||||||
| LastUpdateDate: | 10/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL007797 | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.