Provider Demographics
NPI:1629295415
Name:CLARK, LAURA BETH (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
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 1:426 INDUSTRIAL AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4448
Mailing Address - Country:US
Mailing Address - Phone:802-860-4360
Mailing Address - Fax:802-488-3160
Practice Address - Street 1:426 INDUSTRIAL AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4448
Practice Address - Country:US
Practice Address - Phone:802-860-4360
Practice Address - Fax:802-488-3160
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist