MEDICARE: LOLA GENE CLARK MS/CCC-SLP

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	SA 11850	FL

General Provider Information

NPI Number	:	1477991172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOLA GENE CLARK MS/CCC-SLP

Provider Business Mailing Address
First Line	:	4560 ESTERO BLVD
Second Line	:	#202
City	:	FORT MYERS BEACH
State	:	FL
Zip	:	33931-3947
Country	:	US
Telephone Number	:	260-437-2385
Fax Number	:

Provider Business Practice Location Address
First Line	:	4560 ESTERO BLVD
Second Line	:	#202
City	:	FORT MYERS BEACH
State	:	FL
Zip	:	33931-3947
Country	:	US
Telephone Number	:	260-437-2385
Fax Number	:

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

Provider Enumeration Date	:	06/05/2013
Last Update Date	:	06/05/2013

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