Provider Demographics
NPI:1629508908
Name:CLARK, ERIN KAE (ATC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9547 SKOGEN RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523-9756
Mailing Address - Country:US
Mailing Address - Phone:920-296-9183
Mailing Address - Fax:
Practice Address - Street 1:800 W MAIN ST
Practice Address - Street 2:WILLIAMS CENTER 105G
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190
Practice Address - Country:US
Practice Address - Phone:262-472-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI855-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer