Provider Demographics
NPI:1750666426
Name:CLARK, KAITLIN T (PT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:T
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 1:15410 S MOUNTAIN PKWY
Mailing Address - Street 2:STE: 112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7409
Practice Address - Street 1:15410 S MOUNTAIN PKWY
Practice Address - Street 2:STE: 112
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6691
Practice Address - Country:US
Practice Address - Phone:480-706-1161
Practice Address - Fax:480-706-7409
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9504225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic