Provider Demographics
NPI:1780994418
Name:CLARK, MARYBETH GIARLA (MED)
Entity type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:GIARLA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:709 E DEKALB RD
Mailing Address - Street 2:
Mailing Address - City:DE KALB JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:13630-3103
Mailing Address - Country:US
Mailing Address - Phone:315-347-3442
Mailing Address - Fax:315-347-3817
Practice Address - Street 1:709 E DEKALB RD
Practice Address - Street 2:
Practice Address - City:DE KALB JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:13630-3103
Practice Address - Country:US
Practice Address - Phone:315-347-3442
Practice Address - Fax:315-347-3817
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018557-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist