Provider Demographics
NPI:1215122007
Name:CLARK, NOEL ANNE (MS CCC SLP)
Entity type:Individual
Prefix:MS
First Name:NOEL
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
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 1:4517 N LARKIN ST
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1543
Mailing Address - Country:US
Mailing Address - Phone:414-393-8835
Mailing Address - Fax:
Practice Address - Street 1:4517 N LARKIN ST
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1543
Practice Address - Country:US
Practice Address - Phone:414-393-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146 008259235Z00000X
WI3076 154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist