Provider Demographics
NPI:1902336753
Name:CLARK, MELISSA LYNN (AUD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN STREET
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4650
Mailing Address - Country:US
Mailing Address - Phone:802-747-3639
Mailing Address - Fax:802-747-6207
Practice Address - Street 1:69 ALLEN ST STE 1
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:802-775-3315
Practice Address - Fax:802-775-9617
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0123131231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist