Provider Demographics
NPI:1467829911
Name:CLARK, CRYSTAL LYNN (MS, ATC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2504
Mailing Address - Country:US
Mailing Address - Phone:734-395-9716
Mailing Address - Fax:
Practice Address - Street 1:1500 MANLEY ST
Practice Address - Street 2:DALTON HIGH SCHOOL
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-4088
Practice Address - Country:US
Practice Address - Phone:734-395-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0020552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer