Provider Demographics
NPI:1104836170
Name:CLARK, CANDY M (P T)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-0537
Mailing Address - Country:US
Mailing Address - Phone:979-542-0223
Mailing Address - Fax:979-542-1993
Practice Address - Street 1:781 E BRENHAM ST
Practice Address - Street 2:
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-2129
Practice Address - Country:US
Practice Address - Phone:979-542-0223
Practice Address - Fax:979-542-1993
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1040368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist