Healthcare Provider Details

I. General information

NPI: 1124044060
Provider Name (Legal Business Name): DIANA MARCELA CLARK M.S., SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD STE 700
LONG BEACH CA
90807-2000
US

IV. Provider business mailing address

6546 E CHANNEL DR
HERNANDO FL
34442-3708
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-2273
  • Fax: 818-357-2505
Mailing address:
  • Phone: 786-246-5967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number144.0134728
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19290
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8620
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: