Provider Demographics
NPI:1376892422
Name:CLARK, TAYLOR J (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:J
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 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-2751
Mailing Address - Fax:864-512-3719
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1198
Practice Address - Fax:864-512-3608
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC67752251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH2535Medicaid