Provider Demographics
NPI:1912739350
Name:CLARK, CAMILLE ANN (BA)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59241 REBEL DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-3713
Mailing Address - Country:US
Mailing Address - Phone:985-641-6510
Mailing Address - Fax:
Practice Address - Street 1:59241 REBEL DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-3713
Practice Address - Country:US
Practice Address - Phone:985-641-6510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant