1558873273 NPI number — MRS. MEGHAN REBECCA CLARK MS CCC-SLP

Table of content: MRS. MEGHAN REBECCA CLARK MS CCC-SLP (NPI 1558873273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558873273 NPI number — MRS. MEGHAN REBECCA CLARK MS CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MEGHAN
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558873273
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 BROOKFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42001-5306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-293-6374
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 FERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62910-2891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-564-2482
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  1915639 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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