Provider Demographics
NPI:1760474043
Name:CLARK, STEVEN BRADLEY (MPT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:BRADLEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 COBBLE STONE DR
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-5501
Mailing Address - Country:US
Mailing Address - Phone:662-241-4545
Mailing Address - Fax:662-241-4025
Practice Address - Street 1:65 DUTCH LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-5523
Practice Address - Country:US
Practice Address - Phone:662-241-4545
Practice Address - Fax:662-241-4025
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ36393Medicare UPIN