MEDICARE: HEIDI S CLARK MA, 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

General Provider Information

NPI Number	:	1649520560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI S CLARK MA, CCC-SLP

Provider Business Mailing Address
First Line	:	1000 E UNIVERSITY AVE DEPT 3311
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82071-2001
Country	:	US
Telephone Number	:	307-766-6426
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 E UNIVERSITY AVE DEPT 3311
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82071-2001
Country	:	US
Telephone Number	:	307-766-6426
Fax Number	:

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

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	10/27/2020

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