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NPI Code Detail

MEDICARE: MRS. STACI M CLARK M.A., CCC-SLP

MEDICARE: MRS. STACI M CLARK M.A., 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
1235Z00000XSpeech-Language Pathologist3567SC

General Provider Information

NPI Number : 1841218732
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. STACI M CLARK M.A., CCC-SLP
Provider Business Mailing Address
First Line : 200 BROUGHTON DR
Second Line :
City : GREENVILLE
State : SC
Zip : 29609-3841
Country : US
Telephone Number : 864-233-7905
Fax Number : 864-233-7905
Provider Business Practice Location Address
First Line : 355 OAK GROVE RD
Second Line :
City : SPARTANBURG
State : SC
Zip : 29301-2537
Country : US
Telephone Number : 864-595-4225
Fax Number : 864-595-4821
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/18/2006
Last Update Date : 07/08/2007

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