Provider Demographics
NPI:1619911732
Name:CLARK, SARA MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MELISSA
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 1:6108 SADDLE HORSE LN
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4343
Mailing Address - Country:US
Mailing Address - Phone:850-682-2988
Mailing Address - Fax:
Practice Address - Street 1:1078 S FERDON BLVD
Practice Address - Street 2:CRESTVIEW CHIROPRACTIC CLINIC
Practice Address - City:CRTESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536
Practice Address - Country:US
Practice Address - Phone:850-682-0381
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist