MEDICARE: DANA LYNN CLARK SLPA

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	2355S0801X	Speech-Language Assistant	SP 60198505	WA

General Provider Information

NPI Number	:	1750620381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA LYNN CLARK SLPA

Provider Business Mailing Address
First Line	:	9303 SANDRIDGE RD
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-5102
Country	:	US
Telephone Number	:	360-642-0512
Fax Number	:

Provider Business Practice Location Address
First Line	:	9303 SANDRIDGE RD
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-5102
Country	:	US
Telephone Number	:	360-642-0512
Fax Number	:

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

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	02/01/2013

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