Individual
SHANNON CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1208 IH 35 N STE Q, ROUND ROCK, TX 78681-4204
(512) 310-7665
(512) 310-9228
Mailing address
1208 IH 35 N STE Q, ROUND ROCK, TX 78681-4204
(512) 310-7665
(512) 310-9228
Taxonomy
Speciality
Code
Description
License number
State
2355S0801X
Speech-Language Assistant
Primary
35304
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0031DG
BLUE CROSS BLUE SHIELD
—
05
—
0944746-02
—
TX
01
—
74-2745294
TAX ID
—
Enumeration date
11/19/2009
Last updated
11/19/2009
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