Provider Demographics
NPI:1790003911
Name:CLARK, BROOKE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-999-2030
Mailing Address - Fax:419-991-0909
Practice Address - Street 1:640 WORTH STREET
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-8515
Practice Address - Country:US
Practice Address - Phone:814-664-9606
Practice Address - Fax:814-665-0036
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000420225200000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant