Provider Demographics
NPI:1225770001
Name:HOLTER, CLARKE (MS, ATC, NASM-PES, C)
Entity Type:Individual
Prefix:
First Name:CLARKE
Middle Name:
Last Name:HOLTER
Suffix:
Gender:M
Credentials:MS, ATC, NASM-PES, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11443 DYER LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4968
Mailing Address - Country:US
Mailing Address - Phone:205-523-1628
Mailing Address - Fax:
Practice Address - Street 1:1201 COLISEUM DRIVE ROOM 314
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35487-0001
Practice Address - Country:US
Practice Address - Phone:205-523-1628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer