Provider Demographics
NPI:1326063603
Name:CLARK, SUSAN C
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
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 1:19 CENTRAL ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:BYFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01922-1233
Mailing Address - Country:US
Mailing Address - Phone:978-462-4500
Mailing Address - Fax:978-462-1275
Practice Address - Street 1:705 N MOUNTAIN RD
Practice Address - Street 2:SUITE A-212
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1412
Practice Address - Country:US
Practice Address - Phone:860-953-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist