Provider Demographics
NPI:1609585256
Name:CLARK, MELISSA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
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 1:400 W LBJ FWY STE 330
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3717
Mailing Address - Country:US
Mailing Address - Phone:972-556-2885
Mailing Address - Fax:972-506-8733
Practice Address - Street 1:910 E SOUTHLAKE BLVD STE 155
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6389
Practice Address - Country:US
Practice Address - Phone:817-421-5000
Practice Address - Fax:972-506-8733
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11162912251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic