MEDICARE: MRS. MARYBETH GIARLA CLARK M.ED.

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	018557-1	NY

General Provider Information

NPI Number	:	1780994418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARYBETH GIARLA CLARK M.ED.

Provider Business Mailing Address
First Line	:	709 E DEKALB RD
Second Line	:
City	:	DE KALB JUNCTION
State	:	NY
Zip	:	13630-3103
Country	:	US
Telephone Number	:	315-347-3442
Fax Number	:	315-347-3817

Provider Business Practice Location Address
First Line	:	709 E DEKALB RD
Second Line	:
City	:	DE KALB JUNCTION
State	:	NY
Zip	:	13630-3103
Country	:	US
Telephone Number	:	315-347-3442
Fax Number	:	315-347-3817

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

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	10/15/2010

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