Provider Demographics
NPI:1730118381
Name:CLARK, WESLEY ETHAN (PT)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:ETHAN
Last Name:CLARK
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 1:931 YORK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2043
Mailing Address - Country:US
Mailing Address - Phone:972-296-6645
Mailing Address - Fax:972-296-4526
Practice Address - Street 1:931 YORK DR
Practice Address - Street 2:SUITE A
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2043
Practice Address - Country:US
Practice Address - Phone:972-296-6645
Practice Address - Fax:972-296-4526
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1142982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist