Provider Demographics
NPI:1588018600
Name:CLARK, JOANN (PT)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 MICHENER DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6237
Mailing Address - Country:US
Mailing Address - Phone:970-402-0398
Mailing Address - Fax:
Practice Address - Street 1:2730 MICHENER DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6237
Practice Address - Country:US
Practice Address - Phone:970-402-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0005550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL00005550OtherCOLORADO DEPARTMENT OF REGULARTORY AGENCIES