Provider Demographics
NPI:1073392239
Name:CLARK, MARY LUCINDA (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LUCINDA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E PINETREE BLVD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4825
Mailing Address - Country:US
Mailing Address - Phone:229-228-8050
Mailing Address - Fax:
Practice Address - Street 1:2300 E PINETREE BLVD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4825
Practice Address - Country:US
Practice Address - Phone:229-228-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist