Provider Demographics
NPI:1154665669
Name:CLARK, DEBRA MAE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:MAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 S 160TH ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:KS
Mailing Address - Zip Code:66743-9487
Mailing Address - Country:US
Mailing Address - Phone:316-250-4532
Mailing Address - Fax:
Practice Address - Street 1:1502 E CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6718
Practice Address - Country:US
Practice Address - Phone:620-235-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01411225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant