Provider Demographics
NPI:1528230059
Name:CLARK, KRISTINE ELIZABETH (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GREENBRIER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1682
Mailing Address - Country:US
Mailing Address - Phone:434-975-5079
Mailing Address - Fax:434-975-9079
Practice Address - Street 1:500 GREENBRIER DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1682
Practice Address - Country:US
Practice Address - Phone:434-975-5079
Practice Address - Fax:434-975-9079
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist