MEDICARE: MRS. PETRI CLARK SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1588817761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PETRI CLARK SLP

Provider Business Mailing Address
First Line	:	301 S AVALON ST
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-4170
Country	:	US
Telephone Number	:	870-732-8555
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 S AVALON ST
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-4170
Country	:	US
Telephone Number	:	870-732-8555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	10/31/2008

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Directions to “ MRS. PETRI CLARK SLP” Practice Location

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