Provider Demographics
NPI:1306105903
Name:CLARK, KELLY THOMAS (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 FOWLER CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-6366
Mailing Address - Country:US
Mailing Address - Phone:713-201-9902
Mailing Address - Fax:
Practice Address - Street 1:3406 FOWLER CT
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-6366
Practice Address - Country:US
Practice Address - Phone:713-201-9902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist