Provider Demographics
NPI:1508298522
Name:CLARK, STEPHEN THOMAS (PT, DPT, ATC, OCS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT, DPT, ATC, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HIGHWAY 34 E
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6803
Mailing Address - Country:US
Mailing Address - Phone:770-290-8002
Mailing Address - Fax:
Practice Address - Street 1:1025 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6803
Practice Address - Country:US
Practice Address - Phone:770-290-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYCP008179T225100000X
TX1244088225100000X
GAPT011085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist