Provider Demographics
NPI:1790861847
Name:CLARK, KATHRYN MARIE (PT)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:MARIE
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 1:164 SOMERSBY BLVD
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9380
Mailing Address - Country:US
Mailing Address - Phone:912-663-3830
Mailing Address - Fax:
Practice Address - Street 1:1 PEACHTREE DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1200
Practice Address - Country:US
Practice Address - Phone:912-927-0667
Practice Address - Fax:912-927-0678
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007822225100000X
SC5092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist