Provider Demographics
NPI:1477785368
Name:CLARK, KATHLEEN I (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:I
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-229 WAIPAHU DEPOT ST STE 301
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3033
Mailing Address - Country:US
Mailing Address - Phone:808-671-7414
Mailing Address - Fax:808-671-7133
Practice Address - Street 1:94-229 WAIPAHU DEPOT ST STE 301
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3033
Practice Address - Country:US
Practice Address - Phone:808-671-7414
Practice Address - Fax:808-671-7133
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 8855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist