Provider Demographics
NPI:1740290303
Name:CLARK, DELANE F (PT)
Entity type:Individual
Prefix:
First Name:DELANE
Middle Name:F
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 1:841 BETH HAVEN CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-8124
Mailing Address - Country:US
Mailing Address - Phone:704-736-0996
Mailing Address - Fax:704-736-0996
Practice Address - Street 1:328 WHIPPOORWILL LN
Practice Address - Street 2:
Practice Address - City:MT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-9765
Practice Address - Country:US
Practice Address - Phone:704-827-3788
Practice Address - Fax:704-827-3799
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212080Medicaid