Provider Demographics
NPI:1083617906
Name:CLARK, CHAD ALAN (MSPT)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:ALAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 GLENROYAL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2174
Mailing Address - Country:US
Mailing Address - Phone:719-565-6678
Mailing Address - Fax:719-561-0577
Practice Address - Street 1:58 GLENROYAL DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2174
Practice Address - Country:US
Practice Address - Phone:719-565-6678
Practice Address - Fax:719-561-0577
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36630233Medicaid