Provider Demographics
NPI:1376627885
Name:CLARK, ROBERT L (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:538 ACADIA DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6681
Mailing Address - Country:US
Mailing Address - Phone:707-778-2388
Mailing Address - Fax:707-763-2130
Practice Address - Street 1:169 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2344
Practice Address - Country:US
Practice Address - Phone:707-763-0115
Practice Address - Fax:707-763-2130
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP.T. 10768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT 107680Medicare ID - Type Unspecified