Provider Demographics
NPI:1679770465
Name:CLARK, CORRINE ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:CORRINE
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 FELICITA LN
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-6631
Mailing Address - Country:US
Mailing Address - Phone:760-489-2666
Mailing Address - Fax:
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:760-510-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT210582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic