Provider Demographics
NPI:1346536802
Name:CLARK, BRENDA J (LMT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19626 NARA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-3478
Mailing Address - Country:US
Mailing Address - Phone:713-492-7767
Mailing Address - Fax:
Practice Address - Street 1:19626 NARA VISTA DR
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377-3478
Practice Address - Country:US
Practice Address - Phone:713-492-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT046374225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist