Provider Demographics
NPI:1033535620
Name:CLACK, THALALINE MAYER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THALALINE
Middle Name:MAYER
Last Name:CLACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 BREEZEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30014-0793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 GEORGIA HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-0793
Practice Address - Country:US
Practice Address - Phone:812-345-2685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist