Provider Demographics
NPI:1790786176
Name:CLARK, JOAN M (PT)
Entity Type:Individual
Prefix:MISS
First Name:JOAN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:285 JEFFERSON DR W
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2404
Mailing Address - Country:US
Mailing Address - Phone:434-589-8865
Mailing Address - Fax:434-589-8865
Practice Address - Street 1:285 JEFFERSON DR W
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2404
Practice Address - Country:US
Practice Address - Phone:434-589-8865
Practice Address - Fax:434-589-8865
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist