Provider Demographics
NPI:1295376747
Name:CLARK, JULIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3117
Practice Address - Country:US
Practice Address - Phone:860-933-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer