Provider Demographics
NPI:1275571465
Name:CLARK, ANNE C (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:C
Other - Last Name:CASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6465 JASMINE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6704
Mailing Address - Country:US
Mailing Address - Phone:714-374-4383
Mailing Address - Fax:
Practice Address - Street 1:2500 MAIN STREET
Practice Address - Street 2:250
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648
Practice Address - Country:US
Practice Address - Phone:714-374-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335322251X0800X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK17401Medicare PIN