Provider Demographics
NPI:1063195048
Name:CLARKE, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TRAVERTINE WAY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2402
Mailing Address - Country:US
Mailing Address - Phone:302-241-5961
Mailing Address - Fax:
Practice Address - Street 1:3 TRAVERTINE WAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-2402
Practice Address - Country:US
Practice Address - Phone:302-241-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEO1-0012260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist