Provider Demographics
NPI:1093757213
Name:CLARK, KETA O'NEAL (PT)
Entity Type:Individual
Prefix:MRS
First Name:KETA
Middle Name:O'NEAL
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 1:790 COLLEGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-847-0641
Mailing Address - Fax:802-847-7963
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-1902
Practice Address - Fax:802-847-7963
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist