Provider Demographics
NPI:1396000998
Name:CLARK, STEPHEN B (DPT, MS, ATC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT, MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:83 JOHN CARVER RD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-2028
Mailing Address - Country:US
Mailing Address - Phone:617-610-0690
Mailing Address - Fax:
Practice Address - Street 1:369 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-4402
Practice Address - Country:US
Practice Address - Phone:617-399-7330
Practice Address - Fax:617-399-7331
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAT16462255A2300X
MAPTL20174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer