Provider Demographics
NPI:1114483336
Name:CLARK, BRENDON MATTHEW
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:MATTHEW
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8127 HEATHERY PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-2280
Mailing Address - Country:US
Mailing Address - Phone:317-246-7549
Mailing Address - Fax:
Practice Address - Street 1:8127 HEATHERY PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-2280
Practice Address - Country:US
Practice Address - Phone:317-246-7549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer