Provider Demographics
NPI:1326567116
Name:CLANTON, MARY DENISE (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DENISE
Last Name:CLANTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14875 S SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-3328
Mailing Address - Country:US
Mailing Address - Phone:913-244-5020
Mailing Address - Fax:
Practice Address - Street 1:9700 W 62ND ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-3220
Practice Address - Country:US
Practice Address - Phone:913-384-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01813225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant