Provider Demographics
NPI:1043809932
Name:CLEMENT, THOMAS JOHN (PTA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 SUN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-3745
Mailing Address - Country:US
Mailing Address - Phone:419-885-0291
Mailing Address - Fax:
Practice Address - Street 1:5855 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2269
Practice Address - Country:US
Practice Address - Phone:419-291-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant