Provider Demographics
NPI:1164623724
Name:CLARK, CECILIA I (CMT)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:I
Last Name:CLARK
Suffix:
Gender:F
Credentials:CMT
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 684
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:CO
Mailing Address - Zip Code:80421-0684
Mailing Address - Country:US
Mailing Address - Phone:303-506-5603
Mailing Address - Fax:
Practice Address - Street 1:25 HIGHLANDS DR
Practice Address - Street 2:
Practice Address - City:BAILEY
Practice Address - State:CO
Practice Address - Zip Code:80421-1223
Practice Address - Country:US
Practice Address - Phone:303-506-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist