Provider Demographics
NPI:1649520560
Name:CLARK, HEIDI S (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:S
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 1:1000 E UNIVERSITY AVE DEPT 3311
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82071-2001
Mailing Address - Country:US
Mailing Address - Phone:307-766-6426
Mailing Address - Fax:
Practice Address - Street 1:1000 E UNIVERSITY AVE DEPT 3311
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82071-2001
Practice Address - Country:US
Practice Address - Phone:307-766-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist