Provider Demographics
NPI:1639342702
Name:CLARKE, LISA PATRICE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:PATRICE
Last Name:CLARKE
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 1:307 INTERNATIONAL CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1387
Mailing Address - Country:US
Mailing Address - Phone:410-667-7200
Mailing Address - Fax:
Practice Address - Street 1:301 INTERNATIONAL CIR # 100
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-1334
Practice Address - Country:US
Practice Address - Phone:240-413-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0368791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist