Provider Demographics
NPI:1083355796
Name:CLARK, ASHLEY VICTORIA (PTA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:VICTORIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:VICTORIA
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1274 ELMHURST CIR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2726
Mailing Address - Country:US
Mailing Address - Phone:404-494-0721
Mailing Address - Fax:
Practice Address - Street 1:500 SPRINGHOUSE CIR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6741
Practice Address - Country:US
Practice Address - Phone:678-684-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004397225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant