Healthcare Provider Details

I. General information

NPI: 1063195048
Provider Name (Legal Business Name): MARY CLARKE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 PEOPLES PLZ STE 142
NEWARK DE
19702-4798
US

IV. Provider business mailing address

560 PEOPLES PLZ STE 142
NEWARK DE
19702-4798
US

V. Phone/Fax

Practice location:
  • Phone: 302-542-1481
  • Fax:
Mailing address:
  • Phone: 302-542-1481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberO1-0012260
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: