Provider Demographics
NPI:1801935424
Name:CLARK, DEBORAH WILSON (AUD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:WILSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:DEBORAH
Other - Middle Name:SUZANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:496 1ST ST STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3677
Mailing Address - Country:US
Mailing Address - Phone:650-941-0664
Mailing Address - Fax:650-941-2892
Practice Address - Street 1:496 1ST ST STE 120
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-3677
Practice Address - Country:US
Practice Address - Phone:650-941-0664
Practice Address - Fax:650-941-2892
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 1833237600000X
CA1833231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0023741Medicaid
CAGR0023741Medicaid