Provider Demographics
NPI:1700187564
Name:CLARK, ELIZABETH B (MPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:BUNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:155 SIEMERS DR STE 8
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4910
Mailing Address - Country:US
Mailing Address - Phone:573-334-6711
Mailing Address - Fax:
Practice Address - Street 1:155 SIEMERS DR STE 8
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4910
Practice Address - Country:US
Practice Address - Phone:573-334-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist