Provider Demographics
NPI:1013383926
Name:BRAINERD, CLARK (PT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:BRAINERD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 NEW MEXICO AVE NW
Mailing Address - Street 2:SUITE 318
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-3622
Mailing Address - Country:US
Mailing Address - Phone:202-363-0454
Mailing Address - Fax:202-363-0668
Practice Address - Street 1:8722 GLENARDEN CIR NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-1600
Practice Address - Country:US
Practice Address - Phone:330-685-4384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT871879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG02816Medicare PIN
DC449794YT9Medicare PIN