Provider Demographics
NPI:1497798789
Name:CLARKE, DEANNA JEAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:JEAN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 ISAIAH ST
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-6606
Mailing Address - Country:US
Mailing Address - Phone:715-298-1059
Mailing Address - Fax:
Practice Address - Street 1:16 MENARD PLZ
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4119
Practice Address - Country:US
Practice Address - Phone:715-845-2942
Practice Address - Fax:715-842-3416
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI784019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant