Provider Demographics
NPI:1679774806
Name:CLARKE, EVERALD (PT)
Entity Type:Individual
Prefix:
First Name:EVERALD
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 GINKGO LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5395
Mailing Address - Country:US
Mailing Address - Phone:706-631-2082
Mailing Address - Fax:
Practice Address - Street 1:133 GINKGO LN
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5395
Practice Address - Country:US
Practice Address - Phone:706-631-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007169225100000X
FLPT23048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist