Provider Demographics
NPI:1629388764
Name:CLARK, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2058 S STATE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4786
Mailing Address - Country:US
Mailing Address - Phone:734-913-0300
Mailing Address - Fax:734-913-0400
Practice Address - Street 1:2058 S STATE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4786
Practice Address - Country:US
Practice Address - Phone:734-913-0300
Practice Address - Fax:734-913-0400
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist