Basic Information
| Provider Information | |||||||||
| NPI: | 1124794458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | COURTLYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | C/O: ALYSSA TAYLOR | ||||||||
| Address2: | 2428 LAKE VISTA CT #210 | ||||||||
| City: | CASSELBERRY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417401444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6900 S ORANGE BLOSSOM TRL STE 102 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328095734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214451287 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2021 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | SI4980 | FL | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.