Provider Demographics
NPI:1053476929
Name:CLACK, PAMELA R (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:CLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 LAUNIUS RD
Mailing Address - Street 2:
Mailing Address - City:GOOD HOPE
Mailing Address - State:GA
Mailing Address - Zip Code:30641-2637
Mailing Address - Country:US
Mailing Address - Phone:706-752-0779
Mailing Address - Fax:706-752-1596
Practice Address - Street 1:703 KINGS RDG
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2051
Practice Address - Country:US
Practice Address - Phone:770-207-5788
Practice Address - Fax:770-207-5708
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0014152251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics