Provider Demographics
NPI:1659335859
Name:CLARK, CATHLEEN MARIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:CATHLEEN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4056
Mailing Address - Country:US
Mailing Address - Phone:860-329-2777
Mailing Address - Fax:860-621-1076
Practice Address - Street 1:209 PARTRIDGE DR
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-4056
Practice Address - Country:US
Practice Address - Phone:860-329-2777
Practice Address - Fax:860-621-1076
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0044542251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics