Provider Demographics
NPI:1164984134
Name:CLARK, DAVID NICHOLAS (PT,DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NICHOLAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ALTA ST SW APT D202
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-6103
Mailing Address - Country:US
Mailing Address - Phone:503-707-9541
Mailing Address - Fax:
Practice Address - Street 1:1010 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8892
Practice Address - Country:US
Practice Address - Phone:360-480-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60865775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist