Provider Demographics
NPI:1316327653
Name:CLARK, MALLORY (SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
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 1:2552 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37127-7135
Mailing Address - Country:US
Mailing Address - Phone:615-893-2313
Mailing Address - Fax:
Practice Address - Street 1:2552 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37127-7135
Practice Address - Country:US
Practice Address - Phone:615-893-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4511235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist