Provider Demographics
NPI:1114063245
Name:CLARK, BRIAN HOWARD (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:HOWARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2633
Mailing Address - Country:US
Mailing Address - Phone:256-314-0491
Mailing Address - Fax:256-386-4067
Practice Address - Street 1:1300 S MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-6334
Practice Address - Country:US
Practice Address - Phone:256-386-4005
Practice Address - Fax:256-386-4685
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51513137OtherBLUE CROSS