Provider Demographics
NPI:1407827561
Name:CLARK, TERESA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:POB 2327
Mailing Address - Street 2:STRICKLAND AND BASISTA TC ULTIMATE THERAPY
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650
Mailing Address - Country:US
Mailing Address - Phone:301-997-1155
Mailing Address - Fax:301-997-1199
Practice Address - Street 1:40900 MERCHANTS LANE
Practice Address - Street 2:SUITE 202
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:301-997-1155
Practice Address - Fax:301-997-1199
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20676225100000X
MD22809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist