Provider Demographics
NPI:1316140460
Name:CLARK, CARL HUGH (MS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:HUGH
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 SUNSET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3699
Mailing Address - Country:US
Mailing Address - Phone:406-257-4327
Mailing Address - Fax:407-257-4395
Practice Address - Street 1:795 SUNSET BLVD STE B
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-257-4327
Practice Address - Fax:407-257-4395
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT422231H00000X
MT170237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0569543Medicaid
MT29308OtherAUDIOLOGIST