Provider Demographics
NPI:1376556399
Name:CLARK, TERRI (PT)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5542 JENNY CT
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-9360
Mailing Address - Country:US
Mailing Address - Phone:501-609-6561
Mailing Address - Fax:
Practice Address - Street 1:3331 S STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2458
Practice Address - Country:US
Practice Address - Phone:269-982-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0581OtherLICENSE #
MI5501013139OtherMICHIGAN LICENSE