Provider Demographics
NPI:1790429074
Name:CLARK, ANTHONY G (LMT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:G
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:235 BELLMAN ST
Mailing Address - Street 2:
Mailing Address - City:THROOP
Mailing Address - State:PA
Mailing Address - Zip Code:18512-3304
Mailing Address - Country:US
Mailing Address - Phone:570-780-5858
Mailing Address - Fax:
Practice Address - Street 1:235 BELLMAN ST
Practice Address - Street 2:
Practice Address - City:THROOP
Practice Address - State:PA
Practice Address - Zip Code:18512-3304
Practice Address - Country:US
Practice Address - Phone:570-780-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA-27231225700000X
PAMSG003643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist