Provider Demographics
NPI:1578293114
Name:CLARK, DYLAN EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:EDWARD
Last Name:CLARK
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 1:3 HOBBES CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-3945
Mailing Address - Country:US
Mailing Address - Phone:609-367-3533
Mailing Address - Fax:
Practice Address - Street 1:1600 WILSON BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-2505
Practice Address - Country:US
Practice Address - Phone:703-935-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist