Provider Demographics
NPI:1659385730
Name:CLARK, MERIDITH ELAINE (LPTA)
Entity Type:Individual
Prefix:
First Name:MERIDITH
Middle Name:ELAINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MANNINGS LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4372
Mailing Address - Country:US
Mailing Address - Phone:757-333-6682
Mailing Address - Fax:
Practice Address - Street 1:1400 FORDHAM DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5368
Practice Address - Country:US
Practice Address - Phone:757-361-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601578225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant