Provider Demographics
NPI:1285779538
Name:CLARK, LAURIE (SLP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-2886
Mailing Address - Country:US
Mailing Address - Phone:603-459-2725
Mailing Address - Fax:603-459-2783
Practice Address - Street 1:144 CANAL ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064-2886
Practice Address - Country:US
Practice Address - Phone:603-459-2725
Practice Address - Fax:603-459-2783
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3071948Medicaid
NH6606699Y0NH01Medicare UPIN
NH8250285Medicare UPIN