Provider Demographics
NPI:1194177766
Name:CLACK, STEPHEN F (PT,DPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:F
Last Name:CLACK
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 1:460 MALL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4801
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-3369
Practice Address - Street 1:210 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-3369
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist