Provider Demographics
NPI:1598325896
Name:CLARK, TERRI A (PTA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20047 AVOCET LN
Mailing Address - Street 2:
Mailing Address - City:THACKERVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:73459-9009
Mailing Address - Country:US
Mailing Address - Phone:580-276-6276
Mailing Address - Fax:
Practice Address - Street 1:1900 ONEAL ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-3604
Practice Address - Country:US
Practice Address - Phone:940-665-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2057130225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant