Provider Demographics
NPI:1306033857
Name:ULLERICH, CLARK (MPT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:ULLERICH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-2654
Mailing Address - Country:US
Mailing Address - Phone:641-660-3652
Mailing Address - Fax:
Practice Address - Street 1:308 SE 9TH ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-2296
Practice Address - Country:US
Practice Address - Phone:866-588-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist