Provider Demographics
NPI:1003196718
Name:CLARK, SHELLEY (DPT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 ROCKRIDGE CT APT 5
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9048
Mailing Address - Country:US
Mailing Address - Phone:605-661-0879
Mailing Address - Fax:
Practice Address - Street 1:2803 ROCKRIDGE CT APT 5
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-9048
Practice Address - Country:US
Practice Address - Phone:605-661-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2759225100000X
SD1544225100000X
MT2157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist