Provider Demographics
NPI:1538998620
Name:CLARK, ALICIA (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1669
Mailing Address - Country:US
Mailing Address - Phone:304-369-5719
Mailing Address - Fax:304-369-2930
Practice Address - Street 1:701 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1669
Practice Address - Country:US
Practice Address - Phone:304-369-5719
Practice Address - Fax:304-369-2930
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1219235Z00000X
WV1219235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist