MEDICARE: NYSSA CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP.11340	OH

General Provider Information

NPI Number	:	1477956399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NYSSA CLARK

Provider Business Mailing Address
First Line	:	5750 FLANDERS RD
Second Line	:
City	:	SYLVANIA
State	:	OH
Zip	:	43560-1716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 MARVIN AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-1705
Country	:	US
Telephone Number	:	419-250-4652
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	08/14/2025

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Directions to “ NYSSA CLARK ” Practice Location

Language	Start Address	Practice Location

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