Provider Demographics
NPI:1275131344
Name:CLARK, SHERRY (PTA)
Entity Type:Individual
Prefix:MISS
First Name:SHERRY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 WALL ST SE STE 176
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6703
Mailing Address - Country:US
Mailing Address - Phone:770-679-1553
Mailing Address - Fax:866-666-4344
Practice Address - Street 1:2395 WALL ST SE STE 176
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6703
Practice Address - Country:US
Practice Address - Phone:770-679-1553
Practice Address - Fax:866-666-4344
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004524208100000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation