Provider Demographics
NPI:1164961447
Name:CLARK, AUDREY ANN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ANN
Other - Last Name:WICKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3667
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:252 W MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1065
Practice Address - Country:US
Practice Address - Phone:740-296-5042
Practice Address - Fax:740-296-5320
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT014631225100000X
WVCP015162T225100000X
WVCP008400T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist