Provider Demographics
NPI:1962730531
Name:CLARK, CARRIE CECILIA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:CECILIA
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 1:5014 W MILLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5329
Mailing Address - Country:US
Mailing Address - Phone:573-489-7659
Mailing Address - Fax:
Practice Address - Street 1:5014 W MILLBROOK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5329
Practice Address - Country:US
Practice Address - Phone:573-489-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009002722235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist