Basic Information
| Provider Information | |||||||||
| NPI: | 1760589550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERALEA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 406153 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5616888877 | ||||||||
| Practice Location | |||||||||
| Address1: | 7701 LAKE WORTH RD | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614398821 | ||||||||
| FaxNumber: | 5614395035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | AS2652 | FL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 610124100 | 05 | FL | MEDICAID |