Provider Demographics
NPI:1285929190
Name:CLARK, MARTI S (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARTI
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 E. SUNSHINE STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-732-8480
Mailing Address - Fax:417-732-8480
Practice Address - Street 1:1610 E. SUNSHINE STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-523-7500
Practice Address - Fax:417-523-7595
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112607235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist