Provider Demographics
NPI:1528463593
Name:CLARK, TRACY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
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 1:10749 BARTHOLOMEW RD
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-9084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 YOUNGSTOWN-WARREN RD
Practice Address - Street 2:TCESC
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446
Practice Address - Country:US
Practice Address - Phone:330-505-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
385HR2060X
OHSP 10535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No374U00000XNursing Service Related ProvidersHome Health Aide
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child