Provider Demographics
NPI:1225174295
Name:CLARK, MARY LYNN (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:CLARK
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Gender:F
Credentials:PT
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Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:85 BARNES RD
Practice Address - Street 2:SUITE 109
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1832
Practice Address - Country:US
Practice Address - Phone:203-697-1067
Practice Address - Fax:203-284-0492
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-08-23
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Provider Licenses
StateLicense IDTaxonomies
CT002882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT65000418Medicare PIN