Provider Demographics
NPI:1063101095
Name:CLARKE, TIFFANY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CLARKE
Suffix:
Gender:
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 1:643 LAKELAND EAST DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9032
Mailing Address - Country:US
Mailing Address - Phone:601-824-7020
Mailing Address - Fax:
Practice Address - Street 1:643 LAKELAND EAST DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9032
Practice Address - Country:US
Practice Address - Phone:601-824-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2025-03-04
Deactivation Date:2023-06-12
Deactivation Code:
Reactivation Date:2025-02-12
Provider Licenses
StateLicense IDTaxonomies
MSS5092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist