Provider Demographics
NPI:1235786088
Name:CLARK, EMILY JANE (DPT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WONSETTLER RD
Mailing Address - Street 2:
Mailing Address - City:SCENERY HILL
Mailing Address - State:PA
Mailing Address - Zip Code:15360-1831
Mailing Address - Country:US
Mailing Address - Phone:570-234-5866
Mailing Address - Fax:
Practice Address - Street 1:1160 VAN VOORHIS RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3437
Practice Address - Country:US
Practice Address - Phone:304-598-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA026115225100000X
CA295590225100000X
WV003757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist