Provider Demographics
NPI:1376878595
Name:CLARK, KIMBERLY (MPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 1:101 S KRAEMER BLVD STE 125
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6100
Mailing Address - Country:US
Mailing Address - Phone:714-624-2315
Mailing Address - Fax:
Practice Address - Street 1:101 S KRAEMER BLVD STE 125
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6100
Practice Address - Country:US
Practice Address - Phone:714-624-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA211092251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics