Provider Demographics
NPI:1689874646
Name:SKOOG, CLINT WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:WAYNE
Last Name:SKOOG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8607 UNITED KINGDOM DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6472
Mailing Address - Country:US
Mailing Address - Phone:361-894-4353
Mailing Address - Fax:
Practice Address - Street 1:3200 SLAUGHTER LN W
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5706
Practice Address - Country:US
Practice Address - Phone:512-282-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2048956174400000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No174400000XOther Service ProvidersSpecialist