Provider Demographics
NPI:1073094371
Name:CLARK, MEGAN LATARA (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LATARA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LATARA
Other - Last Name:BUNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:305 NE LOOP 820 BLDG TOWER1
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:2410 E RIVERSIDE DR STE B1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-3052
Practice Address - Country:US
Practice Address - Phone:512-394-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2142280225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant