Provider Demographics
NPI:1174146047
Name:CLARK, GERALYN M (SLP)
Entity type:Individual
Prefix:
First Name:GERALYN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:GERALYN
Other - Middle Name:M
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883-0070
Mailing Address - Country:US
Mailing Address - Phone:989-506-4435
Mailing Address - Fax:
Practice Address - Street 1:4471 SHEFFIELD PL
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2564
Practice Address - Country:US
Practice Address - Phone:989-684-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist