1568092559 NPI number — GABRIELLE L CLARK SLP

Table of content: GABRIELLE L CLARK SLP (NPI 1568092559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568092559 NPI number — GABRIELLE L CLARK SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
GABRIELLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AMBROSE
Provider Other First Name:
GABRIELLE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568092559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1185 W CARMEL DR STE D1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-8708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-450-4180
Provider Business Practice Location Address Fax Number:
317-324-3950
Provider Enumeration Date:
01/19/2020

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:  22006568A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q00139223 . This is a "RAILROAD PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 264430A72 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 300034682 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 063220046 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: Q00478549 . This is a "RAILROAD PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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