Provider Demographics
NPI:1487905451
Name:CLARK, KRISTINA INEZ
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:INEZ
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:INEZ
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1163 QUACKENBUSH RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-5445
Mailing Address - Country:US
Mailing Address - Phone:817-721-3530
Mailing Address - Fax:
Practice Address - Street 1:1270 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2104
Practice Address - Country:US
Practice Address - Phone:518-382-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0222871235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist