Provider Demographics
NPI:1326271644
Name:CLARK, MARISSA EVERLY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:EVERLY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 W 6TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3150
Mailing Address - Country:US
Mailing Address - Phone:785-856-3220
Mailing Address - Fax:785-856-7392
Practice Address - Street 1:3115 W 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3150
Practice Address - Country:US
Practice Address - Phone:785-856-3220
Practice Address - Fax:785-856-7392
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-034382251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology