Provider Demographics
NPI:1629727565
Name:CLARK, DANIEL JAMES (DPT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SHORTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14548-9315
Mailing Address - Country:US
Mailing Address - Phone:585-752-8753
Mailing Address - Fax:
Practice Address - Street 1:1495 MILITARY RD
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1339
Practice Address - Country:US
Practice Address - Phone:716-447-6037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist