Provider Demographics
NPI:1285808188
Name:CLARK, ROY ELLIS (MS, CCC-A)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:ELLIS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 N GLADSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5392
Mailing Address - Country:US
Mailing Address - Phone:812-376-3071
Mailing Address - Fax:812-378-5721
Practice Address - Street 1:1655 N GLADSTONE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5392
Practice Address - Country:US
Practice Address - Phone:812-376-3071
Practice Address - Fax:812-378-5721
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002042231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter