Healthcare Provider Details

I. General information

NPI: 1033021761
Provider Name (Legal Business Name): KATHERINE CLARK M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 GODFREY AVE SW
WYOMING MI
49509-1415
US

IV. Provider business mailing address

1138 OAKLAWN ST NE
GRAND RAPIDS MI
49505-3754
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-0533
  • Fax:
Mailing address:
  • Phone: 616-481-9055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101005392
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: