Provider Demographics
NPI:1225098411
Name:CLARK, BECKY ANN (BS, PT)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS, PT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS, PT
Mailing Address - Street 1:21525 N LITTLE SPOKANE DR
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9478
Mailing Address - Country:US
Mailing Address - Phone:509-466-1850
Mailing Address - Fax:
Practice Address - Street 1:12012 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4887
Practice Address - Country:US
Practice Address - Phone:509-413-1630
Practice Address - Fax:509-413-1673
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0108459OtherLABOR & INDUSTRIES
WA7076995Medicaid
WA7076995Medicaid