Healthcare Provider Details

I. General information

NPI: 1417862202
Provider Name (Legal Business Name): MICHELLE MARIE CLARK M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLY CLARK M.S., CCC-SLP

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7772 PONDEROSA DR
SPRINGFIELD IL
62707-8539
US

IV. Provider business mailing address

7772 PONDEROSA DR
SPRINGFIELD IL
62707-8539
US

V. Phone/Fax

Practice location:
  • Phone: 217-494-5020
  • Fax:
Mailing address:
  • Phone: 217-494-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146005641
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: