Provider Demographics
NPI:1417539263
Name:CLARK, MEGAN (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:
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 1:829 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:MISHICOT
Mailing Address - State:WI
Mailing Address - Zip Code:54228-9464
Mailing Address - Country:US
Mailing Address - Phone:715-432-4425
Mailing Address - Fax:
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5488
Practice Address - Fax:920-288-4707
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5275-154235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist