Provider Demographics
NPI:1558379180
Name:LAWRENCE, CLINTON G (PT)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:G
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1212
Mailing Address - Country:US
Mailing Address - Phone:405-609-3658
Mailing Address - Fax:800-506-3795
Practice Address - Street 1:1714 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3624
Practice Address - Country:US
Practice Address - Phone:405-285-8845
Practice Address - Fax:405-285-8848
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK249517504Medicare ID - Type Unspecified