Provider Demographics
NPI:1396044913
Name:CLARK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8683 W SAHARA AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5878
Mailing Address - Country:US
Mailing Address - Phone:702-369-3338
Mailing Address - Fax:702-878-8761
Practice Address - Street 1:8683 W SAHARA AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5878
Practice Address - Country:US
Practice Address - Phone:702-369-3338
Practice Address - Fax:702-878-8761
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner