Provider Demographics
NPI:1134714389
Name:CLARK, ANNALIESE MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANNALIESE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 WINSLOW LN
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6666
Mailing Address - Country:US
Mailing Address - Phone:636-328-2464
Mailing Address - Fax:
Practice Address - Street 1:2011 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5945
Practice Address - Country:US
Practice Address - Phone:832-241-8160
Practice Address - Fax:832-241-8161
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112874235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist