Provider Demographics
NPI:1811123060
Name:CLARK, ANGELA C (SLP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:CHANCEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6712 FAIRVIEW TER
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-8854
Mailing Address - Country:US
Mailing Address - Phone:863-244-4574
Mailing Address - Fax:
Practice Address - Street 1:6712 FAIRVIEW TER
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-8854
Practice Address - Country:US
Practice Address - Phone:863-244-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA5772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001229500Medicaid
FL001229700Medicaid