Provider Demographics
NPI:1497166490
Name:CLARKE, KATINA C (LMT/EMT/MMP)
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:C
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LMT/EMT/MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 WHIPPOORWILL HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1524
Mailing Address - Country:US
Mailing Address - Phone:203-788-0058
Mailing Address - Fax:
Practice Address - Street 1:7 WHIPPOORWILL HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1524
Practice Address - Country:US
Practice Address - Phone:203-788-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist