Provider Demographics
NPI:1497979298
Name:CLARK, SEAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S COLLEGE AVE
Mailing Address - Street 2:SUITE A4
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2864
Mailing Address - Country:US
Mailing Address - Phone:970-305-2197
Mailing Address - Fax:855-300-9423
Practice Address - Street 1:151 S COLLEGE AVE
Practice Address - Street 2:SUITE A4
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2864
Practice Address - Country:US
Practice Address - Phone:970-305-2197
Practice Address - Fax:855-300-9423
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0016060174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA208020OtherL&I PROVIDER #