Provider Demographics
NPI:1215534821
Name:HEADY, CLARK ALBERT (LMT)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:ALBERT
Last Name:HEADY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HOLCOMB ST APT 13
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3973
Mailing Address - Country:US
Mailing Address - Phone:315-778-1317
Mailing Address - Fax:
Practice Address - Street 1:165 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2677
Practice Address - Country:US
Practice Address - Phone:315-778-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029616225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist