Basic Information
Provider Information
NPI: 1003141425
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: SANDRA
MiddleName: ELLEN
NamePrefix:  
NameSuffix:  
Credential: MS CCC/SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000XSL007797PAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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