=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073144390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK SPEECH THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2020
-----------------------------------------------------
Last Update Date | 01/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2102 ABERNATHY DR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29505-6714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-389-5933
-----------------------------------------------------
Fax | 843-962-5352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2102 ABERNATHY DR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29505-6714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-389-5933
-----------------------------------------------------
Fax | 843-962-5352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | NATALIE CLARK BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-389-5933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------